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SAN JOAQUJ`r:OUNTY ENVIRONMENTAL HEALT— DEPARTMENT SERVICE REQUEST Type of Business or Property ( `�� `(IS FACILITY ID # BUSINESS NAM SERVICE REQUEST �1t C- -9— J J EXT. PHONE# s(P7 L _` FAx# OWNER I OPERATOR EMPLOYEE MZ �� j' CHECK If BILLING ADDRESS ,7 l FACILITY NAME / " S f -! U( (Jl LC- ' 0 PIE: 3&g92 SITE ADDRESS / 5S0 1 S Mi f t -(-S Y%✓ E I Payment Type L O d I `�SZ Street Number Direction Street Name citvZI Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PH0NE#1 EXT. APN # LAND USE APPLICATION # (Z4) 33 —`% 2-& ©Sg- tcoo--S PHONE#2 EXT' BOS DISTRICT LOCATION CODE ( ) 2 CONTRACTOR / SERVICE REQUESTOR J„�y REQUESTOR✓ LA ( `�� `(IS 20� �Qur ��,�,� `�� ` fH K If BILLING ADDRESS ` '� BUSINESS NAM \ �1t C- -9— J J EXT. PHONE# HOME Or MAILING ADORES ion L _` FAx# CITY LD \ EMPLOYEE MZ �� j' STATE ZIP C'-�A � 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 forma 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, Standar TE and FEDERAL laws. ^ A r� APPLICANT'S SIGNATURE: _ fttio� DATE: /V�4'r -) Ot PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tire 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. TA�q SERVICE REQUESTED: �OO L S T /� j�7 �I /e f E C— Y %t J CY'-t F—G4�— H' PAYMENT RECEIVED MAY - 3 2010 SANOCOUNTY ENTAL ENVIRONMENTAL TH DEPARTMENT ACCEPTED BY: L<t �j EMPLOYEE#:3 DATE: S 3 f a ASSIGNED TO: �£� Z EMPLOYEE MZ �� j' DATE: _5/$ 3 f 0 Date Service Completed (if already completed): SERVICECODE: 522 PIE: 3&g92 Fee Amount: 4 2-2 0 . rip Amount Paid �a,?O �-7 Payment Date 1 h Payment Type Invoice # Check # 3'iSZ I Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003