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10/05/2006 10:12 FAX 7148250685 Clayton_GrpLA Z002/002 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S2 0 0t4 (� (o <br /> OWNER/OPERATOR /y // <br /> "C�,/� CHECI(If BILLING ADDRESS <br /> FACILITY NAME "I ow <br /> P (�l1 1 , a �' <br /> SITE ADDRESS 2, t <br /> 2-L Z- .�,4o l i rd cru <br /> Street Number Direction treet Name <br /> ci <br /> ber <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street kum � ree a e D� <br /> CITYSTATE ZIP <br /> Cid i C- _ <br /> PHONE#i ExT• APN# LAND USE APPLICATION# <br /> —75-f - <br /> PHONE#2CSOS DISTRICT 7ATION CO �rr <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS \l ' <br /> BUSINESS NAMEPHONE# ExT' <br /> C �Q L- tA �yl SeA 0 -,i <br /> HOME or MAILING ADDRESS) I FAX# 1 <br /> CITY STATE / U + zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and./or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project O <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATF..*a_ttd, L laws. <br /> APPLICANT'S SIGNATURE: 1�` DATE: <br /> PROPERTY/BUSINESS O%L'NF.R❑ /' ' OPERATOR/MANAGER OTHER AIiTHORIZw.D AG£NTA 0 0,ii /A <br /> !f APPLICANT is not the BILLL1'G PARn proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQ17IN COUNTY ENVIRONMENTAL HEALTH DI_PARTML-NT aS soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �., �: (l` <br /> COMMENTS: <br /> 1 OCT - b 2001, <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: ` EMPLOYEE#: TAL <br /> LTH b6VAPlidEUT <br /> ASSIGNED TO' /' V4 EMPLOYEE#: C7 DATE: w L <br /> Date Service Completed (if already completed): SERVICE CODE: 3vU PIE: (J 7 <br /> Fee Amount: Z Amount Paid S ,(� Payment Date <br /> Payment Type ✓ Invoice# Check# a 3 Received By: <br /> EHD 48-02.025 oi-M SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />