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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # OWNER / OPERATOR A P ctr ylCt m gai4lee Si CHECK if BILLING ADDRESS FACILITY NAME �1 Ph 8 Z6o SITE ADDRESS 2ft 4 e7 0 � tp Street Number Direction Street Name Ci Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name /"' CITY STATE ZIP REQ PHONE #1 Ex-r. APN # LAND USE APPLICATION # ` D ( ) Ak 0 PHONE #2 Exr, BOS DISTRICT LOCA ?020 ( ) H NV R0 UIN O CONTRACTOR / SERVICE REQUESTOR IR 1Y7 REQUESTORCHECK if BILLING ADDRESS E] G c� L\ ak e c3A&4^ BUSINESS NAME - PHONE # Exr•ra +Monz Pe-�o I � � ,,.._ •=Wt. rCt'_ 4 �. c _ 2, - � � o •- 080 HOME or MAILING ADDRESS FAX # to \ C + ( ) CITY /� _ OC j STATE �' ZIP 9 ysQ 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, STATE and FEDERAL laws . / APPLICANT' S SIGNATURE : DATE : 0 7oS — 2-o 2�n PROPERTY / BUSINESS OWNER OPERATOR / ANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT S not the BILLING PARTY, proof of authorization to sign Is required 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 : COMMENTS : '1'0 1•p., l6 ce. e tu54 v � G ) Cj j & rCo g +O ) SO�r4NU-{/ c✓ C ) �2t J > Ce33 'e J� \\ � 8I > 0 M ) d3 y� `h ((tomfie+-.Ice I+ o e%A. A � Y¢ n � a ,ra 't11a T � Co ,'1 Cwn.+ 'xO / r. ACCEPTED BY: , /�✓1 (/`J EMPLOYEE #: DATE: �IU ASSIGNED TO : S �I Y EMPLOYEE M DATE: 5 Date Service Completed (if already comp) ) : SERVICE CODE: / of PIE : 200 Fee Amount : 44E(4p Ott Amount Paid TS(D. O � Payment Date 3 Z(7 Payment Type 45 Invoice # Check # ' �l0 'Ir Received By: EHD 48-02-025 SR FORM (Golden Rod ) 07/ 17/08