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. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTREPARTMENT SERVICE REQUEST Ffi 1�t 61,517 Type of Business or Property FACILITY ID# SERVICE REQUEST# 14r,+ VV- d l I �q- AA- 0 00 52�7G 9� O NER/OPERATOR if ILUNG ADDRESS❑ an3ocimin Obuo - Uc- 00VK& +.- 9bud 0 FACILITY NAME U l4 '1 I La 1 I I SITE ADDRESS /„y N A I I . a �l r�� lV /V W l�'nden Asa 3to Street Number Direction treat Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) 2-10ME E . vy � V� ^ I Street Nuber ' treat ame CITY � fSTATE ZIP 50? I PHONE#1 �1 ExT. APN# LAND USE APPLICATION# cao�) �10�'- 30101 Og3yyDva It)P,3;?9 5 f UP NSI PHONE#2 Exr. BOS DISLOCATION CODE TRICT ( ) O D`1 �T CONTRACTOR/ SERVICE REQUESTOR REQUESTOR G(n o n CHECK if BILLING ADDRESS BUSINESS NAM�h I* � f PHONE# EXT. n11Y1 - L� - u (a09) L1&R- 0 Co HOME or MAILING ADDRESS FAX# d F-- OM) q&�--(307 CITY STATE CY1 ZIP C?Sa0 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 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 FEgz� APPLICANT'S SIGNATURE: ,IT-- f DATE: PROPERTY/BUSINESS OWNER❑ O RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title eh Jj0,ee*- 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: COMMENTS: y)s4*I 1 as►&n W Q n c.r new �r6vhdu�a��r' rn rl,+-f�ri n w ! I nn -j"h- , Brea&f Si6U o- 4�u land-RlI. ACCEPTED BY: ,�/jy j�Ls f� o ,v, vA EMPLOYEE#: -ZV 2-,�) DATE: ASSIGNED TO: �jit � J C X 14 D,� '�✓ EMPLOYEE M y6.g L DATE: `fl /j Y Date Service Completed (if already completed): SERVICE CODE: 9 D PIE: 4*'07 Fee Amount: 3 yip 0 Amount Paid-J }D00/ D Payment Date /0/3/14 Payment Type YS% Invoice# Check# Received By: t6 I EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003