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SAN JOAQU —"OUNTY ENVIRONMENTAL HEALT. EPARTMENT SERVICE REQUEST �T�yp\e�of Business or Property �c 1 /t:Y�lO rl'd �' t� BUSINESS NAMjE�L•Cn OI Poo'l PHONE# FACILITY ID # SERVICE REQUEST# OWNER/OPERATOR J,//��,A ['' %L1..1.I �•{r l��(.• J / Y� `' )/ //Jr /7 /�„ 7- CHECK If BILLING ADDRESS FACILITY NAME WUc „Ib.^r „fl� G U u Y C -Y ULT 12 2015 SITE ADDRESS IRc�a Sheet Number DireeSon C u n ame ' (Good brc Ci ZI Code HOME or MAILING ADDRESS (If Different from She Address) Streit Number (— l�Sttreef Name CITY � , uATE LPC�o PHHONE#1 A/() q / 606 / APN # LAND USE APPLICAToN # PHONE#2T• (� BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR P. _ Ma r I L ( n � CHECK if BILLING ADDRESSr �'J on ;/�� hsrI BUSINESS NAMjE�L•Cn OI Poo'l PHONE# HOME or MAILING ADDRESS] Cr .{ 5 F�:#�.-,) 33 / (�32�1 CITY �© d i STA�/j✓�,J ZlPPgS2 (/ 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 foam. 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 FERE laws. t APPLICANT'S SIGNATURE: I ne/ x DATE: /0 ^ / PROPERTY / BUSINESS OWNER❑ OPRATOR AGER [3OTHER AUTHORIZED AGEN'Sil}J Cc��fi'a L7 IfAPPLICANT is not the BlumPAR 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 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. PAYMENT TYPE OF SERVICE REQUESTED: Q,�^c„ 1 n of) IVED COMMENTS: ULT 12 2015 SAN JOAQUIN COUNTY ENWROMENTAL HEALTH DEPARTMENT ACCEPTED BY: EMPLOYEE #: DATE: O / c- .7 ASSIGNED TO: (� EMPLOYEE #: DATE: 10 Date Service Completed (if already completed): SERVICE CODE:t? 'l 2 P/ . 3!_O2,- Fee Amount: 26 w Amount Paid rY�� . Payment Date 10 112,11 S Payment Type Invoice # Check # I Jh I Received By: EHD 48-02-025 O l/ 95y REVISED 11/17/2003 �(b SR FORM (Golden Rod)