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SAN JOAQUI" 7OUNTY ENVIRONMENTAL HEALT DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # CHECK If BILLING ADDRESS SERVICE REQUEST # _ CC NOV 12 2008 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT BUSINESS NAME P60L 1-56�5-599 k14 ExT. `65;-2 ASSIGNED TO: �"aG.� S C.0 1 #: C/� OWNER/ OPERATOR CHECK If BILLING ADDRESS /L r7p (' SERVICECODE: �3Fee FACILRY NAME UG, � `657 SITE ADDRESS STATE 64- IP 74% Z - �� d i `�5ZVO ILmCt reet Number Direction Street Name Cit Zip Code HOME Or ADDPFSS (IfDifferent from Site Address) /MAILING Street Number Street Name CIN L ^ I \lJ ZIP STATE Zip Cn US' PHONE#1 Ex. APN # LAND Er APPLICATION # PHONE#2 En. BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOA REQUESTOR /�L. r'�Y� C"�.(�. C -[L CHECK If BILLING ADDRESS / _ NOV 12 2008 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT BUSINESS NAME P60L PHONE# /6f ExT. `65;-2 ASSIGNED TO: �"aG.� S C.0 1 #: C/� HOME or MAILING ADDRESS Date Service Completed (if already completed): FAX# SERVICECODE: �3Fee CeI ; z r, I - c (9/G) `657 CITY STATE 64- IP 74% Z - 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" ed on this form. I also certify that I have prepared this applica ' n an t the ork to b performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standard , ST E and DEKA ' aws. APPLICANT'S SIGNATURE' DATE: PROPERTY/BUSINESSOWNER❑ OPERATOR /MANAGER OTHER AUTHORIZED AGENT 144'e." If APPLIC✓1NT Ji not the B/LLING PARTY proof of authorization to sign is required Title ZA AUTHORITION 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 nrny;ArA in me nr my renresentative PAVAAu7&.T t.------- — _-_ __ ._- _ _, TYPE OF SERVICE REQUESTED: {2tE.0 }{�04—(�Tt� /�L. r'�Y� C"�.(�. C -[L ECEIVED COMMENTS: NOV 12 2008 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: O L l y t EMPLOYEE M 4f) .32 - ASSIGNED TO: �"aG.� S C.0 EMPLOYEE #: C/� Date Service Completed (if already completed): SERVICECODE: �3Fee WReceivedBy: Amount: �7� - C� Amount Paid g Payment DaPayment Type ,� Invoice # Check# EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)