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SAN JOAQUIN COUNTY ENVIRONMENTAL H EA LTII DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # AERVICE RES1UESTA Soov- 35'J OWNER! OPERATOR ct.,&4,6_ ws(a."4,6- L CHECK If BILLING ADDRESS FACIUTY NAME f--. ksiV: C.e.V•‘• .Z..) ; C>jc /C--, SITE ADDRESS ri,40\ Street Number s • Direction ittevl----\--t-es1 , t Name OW \J Zip Zip Code HOME Or MAIUNG ADDRESS (If DiffctIrent from Site Address) 2-0 6- 2 - \''r-1\ ^ a.C.V-- )fl-. Street Number Street Name CITY iA. D A c3.-kc. STATE ZIP La cks)54* PHONE #1 ( 2-D9 66 9 — q I r-4-- APN # \c‘\—\1:)— 6 \ LAND USE APPLICATION # PHONE in ( ) SOS DISTRICT I LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR *h 'p.-kr2.bt- &viz ,..AA. A CHECK it BILLING ADDRESS BUSINESS NAME A.A." LE, -,..A 4#• e ( IV k 71-N p... c--- PHONE # HOME or MAILING ADDRESS 7-2-or 1 cp‘g-i-#.tte-ck DA- . FAX # ( ) CITY Vikzziez 4.,. 04_ STATE ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project sp cific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busif ss as identified on this form. I also certify that I have prepared this ap !cation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar S 1 TE and FEDERAL laws. APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER ERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is MI th ILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEAS 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. Pit TYPE OF SERVICE REQUESTED: 1) Ul..,,, 124 d l'ek,...> r ir COMMENTS: fit.0 Ce- EA) cae:),\ .C,‘7 .4 z .( C (L _ r\)/5 e-4ZA 14-- t- oet 1 l'ixit7 -1 /1/'?o,Y/1^ ACCEPTED BY: Cct I isk C c-, t c--, EMPLOYEE #: DATE: ( 0 ASSIGNED TO: L._ ,\,, \e\c--u2.7)--- EMPLOYEE #: DATE: I 0 , Date Service Completed (if already completed): SERVICE CODE: 6.2,-23 PIE: (r‘D'o ( Fee Amount: .4---(0 --- Amount Paid i-715-‘0., 60 Payment Date /04 LiE11).1 Payment Type \ ii's ,61._____ Invoice # Check # / ,..,041_,g 2,3 41_ Received y: DATE: EHD 48-02.025 SR FORM (Golden Rod) REVISED 11/17/2003