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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property 0 FACILITY ID # CHECK if BILLING ADDRESS SERVICE REQUEST # i G rrner incl n dfi II PHONE# EXT. -l► SOU -5 1; F2 0,00 l 7 ASSIGNED TO: '"p lLy✓� 2� OWNER/ OPERATOR STATE �f ZIP 9 2(D 4f5 CHECK if BILLING ADDRESS "ytm i nG cove, arl rra (J� V Fee Amount: a�' Amount Paid FACILITY NAME co�� cantractror.� Payment Type ✓ Invoice # SITE ADDRESS S EI por�d� st s 2 �50JCkto 3 2 L Street Number Direction Street N Zi e HOME or MAILING ADDRESS (If Different from Site Address) 2 Dr - --411 Street Number Street Name CITY STATE ZIP Stv C*to 11 C4q5 241 PHONE #1T ( 5 o) (� .��5' j '� APN # /7 % O�2 0,;z LAND USE APPLICATION # PHONE #2UBOS gC40''3Li-�b DISTRICT 1 LOCATION CODE ) � ✓ CONTRACTOR / SERVICE REQUESTOR REQUESTOR 0 Jeffrey l3ei'►n I_'itt CHECK if BILLING ADDRESS BUSINESS NAME Ntiller Brc:uvs >invironmental, Inc. ACCEPTED BY:?J�, PHONE# EXT. -l► SOU -5 1; HOME or MAILING ADDRESS '1I MIT !Et 90te 14 top ASSIGNED TO: '"p lLy✓� FAx# ( 719 ) Kira - 2 1Fz CITY H ulrt1l?gton Fx�aC , STATE �f ZIP 9 2(D 4f5 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STAGE and FEDERAL laws. APPLICANT'S SIGNATURE: l ? DATE: PROPERTY / BUSINESS OWNER ❑ OPERATOR i MANAGER C OTHER AUTHORIZED AGENT ed(C" If APPLICANT is not the BILLING PARTY. proof of authorization to sign is required J Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: r j /-A t/- �� 1^ - -% A`�/, . JE .-- " COMMENTS: Fi/�S�o,g _ ��a trd�t4 �-r m� w�C Co�c�-fr u b n Mill -10,4 AyS 4r"w-1O* — o;� — BA=7� 1 1'Lr JOAQUIN COUNTY _' L/ ��SAN 7/p/off G wGle �d� ��r!/- �'llrtl-$� ti75 E�,ONMENT F 7 / O - 04�e V4,6Vn Atle& '/-W,,& 6201, � �'!l — Y/�S LTH DEPARTMENT ACCEPTED BY:?J�, EMPLOYEE #: DATE: kkvllp ASSIGNED TO: '"p lLy✓� EMPLOYEE #: 116 $-0 DATE: 51-07A-9 Date Service Completed (if already completed): SERVICE CODE: PIE: 4/W'7 Fee Amount: a�' Amount Paid Payment Date a.6 0? Payment Type ✓ Invoice # Check # 82 "71 f Received By: -:let EHDSED 11/1 C�AL OLJU D % � 0•-o -J a� ��`Q SR FORM (Golden Rod) REVISED 11/17/2003