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SAN JOAQUr `OUNTY ENVIRONMENTAL HEALT )EPARTMENT SERVICE REQUEST Type of Business or Property BUSINESS NAME FACILITY ID # SERVICE REQUEST # FAX# CITY STATE ZIP FR Delo a i o a [3f-DO603 OWNER I OPERATOR J. 4. C'+M0}C {�j �fA T{}LLi CHECK If BILLING ADDRESS FACILITY NAME F Date Service Completed (if already completed): SERVICE CODE: S22 SITE ADDRESS a2.7 C(J Slrllt�ilJ ��!7 s>�—DGIL%'�,(J Street Nu tuber Direction Slreel Name Cil Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Payment Type i7 Invoice # O ( 7�//Q Street Number Street Name CITY STATE ZIP 57-0C 4 CA- 9'3-2c7 PHONE #1 EXT. APN# /00 LAND USE APPLICATION# (-7ZM) 'f76-0666 0q90 /66 PHONE#2 EXT. c l BOS DISTRICT LOCATION CODE � CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME PHONE# E'. HOME or MAILING ADDRESS FAX# CITY STATE ZIP BILLING ACKNOWLEDGEMENT: 1, 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: G- 2-4N 0 PROPERTY/ BUSINESS OWNER 06 OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 If APPLICANT is 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: p o L- IS 10t4 A.Jr= O4l 44 Ae-6M O 1J£L LY -4 �E COMMENTS: 1 fCOUNT p Q� n i Bit f l ��777 i:,� ��•Y `VE� T, �Cg 2010 JUN IN sANENOgOONMI JT H�-TH ACCEPTED BY: ©Lt vp- I EMPLOYEEM O?�"� DATE: 4,a'?/10 ASSIGNED TO: �� Q Z� EMPLOYEE M �r�' DATE: 6 /ZQ 1 O Date Service Completed (if already completed): SERVICE CODE: S22 PIE:��L — Fee Amount: 2p, Amount Paid�� Payment Date al -k? /0 Payment Type i7 Invoice # Check # Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003