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SAN JOAQUIN COUNTY ENVIRMISIENTAL HEALTH DEPARTMENT SERVICE REOUEST Type of Business or Property 1 Gr FACCIILITY 16 7---] CHECK If BILLING ADDRESS® SERVICE REQUEST # t�o� (Zen�c(cl PHONE # a 537 -ado HOME or MAIuNo ADDRESS Sdou L -Z-Z r FAx # (a11 )CS CITY EMPLOYEE #: (� 7 J ( STATE Ca OWNER / OPERATOR CHECK If BILLING ADDRESS ❑ D L Date Service Completed (If already Completed): SERVICE CODE: b r •VtA G i PIE: ' Cp0 ?> Fee Amount: 139 00 Amount Paid Payment Date ` cl 7 Payment Type ✓ FACILITY NAME , (c i c, Check # s Received By: n - - SITE ADDRESS � O S 1UL �, l � tmtN ber t ZI o 06— HOME Of MAiuNo ADDRESS (If Different from Site Address) 9trest Number Street Name CITY STATE ZIP PHONE #1 1 ) APN 111 i) 0 I D 7 LAND USE APPUCAnON # PHONIER 1 ) BOS DISTRICT U LOCATION CODE o CONTRACTOR / SERVICE REOUESTOR REQUESTOR � 1 Gr COMMENTS: �J1 ��•nedc(//lc�lasler CHECK If BILLING ADDRESS® BUSINESS NAME t�o� (Zen�c(cl PHONE # a 537 -ado HOME or MAIuNo ADDRESS Sdou Y FAx # (a11 )CS CITY EMPLOYEE #: (� 7 J ( STATE Ca ZIP S30 BILLING ACKNOWLL►GEMENT: 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 I COUNTY Ordinance Codes, Standards, work to be performed will be done in accordance with all SAH JOAQUIN APPLICANT'S SIGNATURE: Z DATE: PROPERTY/ BUSINESS OWNER ❑ OPE TOR MANAGER ❑ OTHER AUTHORIZED AGENT UbCfflfd0� If APPLICANT is not the B 1NG PARTY proof of authorization to sign is required Title p:itTt30Rt7ATION 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 inforrnation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is nrovided to me or my representative. TYPE OF SERVICE REQUESTED: _ r -1 ' (\ Z.0 ., C :v, -S COMMENTS: �J1 ��•nedc(//lc�lasler RECEIVED 1 OCT 9 2001 SAEN OAQUIN COON ACCEPTED BY: V C ,� ;� EMPLOYEE #: (� 7 J ( AHI%F kk ASSIGNEDTO: (-` -�-+',u. F— EMPLOYEE#: Q C( G DATE: 7 a ,7 / C)y Date Service Completed (If already Completed): SERVICE CODE: b r PIE: ' Cp0 ?> Fee Amount: 139 00 Amount Paid Payment Date ` cl 7 Payment Type ✓ I invoice # Check # s Received By: n - EMD -A8-02-025 SR FORM (Golden Rod) REVISED 11/1712003