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SAN JOA( IN COUNTY ENVIRONMENTAL HEALTh DEPARTMENT SERVICE REQUEST Type of Business or Propert FACILITY ID # BUSINESS NAM � SERVICE REQUEST #]`�" S� �� v liDYtccc4i.�^) TVa� PHONE# HOME or MAILItJG ASp �DDRF I2iV ,Kl 1 D I ^ FAX # AA_��,Fp�P(-CHECK OWNERIOPERATe"ri auvki\ /: �f' f 7) STATE zip a If BILLING ADDRESS Date Service Completed (if already completed): FACILITY NAME Q GOrvICr Ci PIE: SITE ADDRESS I ( J 1-rm•_bA€rt I• 1 Amount Paid f (P��Q / rA J FJ 1 Payment Date �' I _ y0/ � Ali �S�'Z0� V -IQ ei Direction Street Nam�eV ZI Cotle HOME Or MAILING ADDRES (if Different from ite Addr s),,,,' D) ` v.str¢et Number Street Name CITY t1 Sm ZIP yy\1 1,J ily �I PHONE #t APN # LAND USE APPLICATION # 02,T) 'T911 PHONE #2 E"r ( I S) lDZ • g,,Z BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTO A c;v J A CHECK If BILLING ADDRESS r� BUSINESS NAM � COMMENTS: n C�� PHONE# HOME or MAILItJG ASp �DDRF I2iV ,Kl 1 D I ^ FAX # CITY r 1 .u9 /` /: �f' f 7) STATE zip 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. 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.' o �, (L APPLICANT'S SIGNATUR—/E:G^%5or �/��L'% `/ DATE: PROPERTY I BUSINESS OWNER IR/ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ ' If APPLICANT Is not the BILLING PARTY, proof Of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 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: FLOP R) 1 `,%I AJ� COMMENTS: n C�� ppww NmhNT iA RECEIVED JUN 0 9 20V AN JOAQUIN COUNTY ACCEPTED BY: {fii � �.}�T 1 1� v v EMPLOYEEM 'I ASSIGNED TO: EMPLOYEE#: DATE: U 111117 Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: 300 1 Amount Paid CO Cp Payment Date Payment Type,l Invoice # Check # 7 7 Received B EHD 48-02-025 SR FORM (Golden Rod) 07/17/08