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SAN JOAQUIlv (70U-1•TTY ENVIRONMENTAL HEALTEWEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # ;25'0_5 SERVICE REQUEST # Sget -7 d Se OWNER / OPERATOR CHECK if Ca BILLING ADDRESS FACILITY NAME ./,-- ;."-V21 Az: rCa der0 14/e s •i'L .e,/k-1,c SITE ADDRESS ,' 67 /3 Direction ZF AL6are_dera Or, Street Name il47) ip Code (".4.4 Street Number HOME or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 Evr. APN # LAND USE APPLICATION # PHONE #2 EXT. BOS DISTRICT LOCATION CODE / CONTRACTOR / SERVICE REQUESTOR REQUESTOR D4u t 13 A.4...„„) A.--( -z-- CHECK if BILLING ADDRESS a- BUSINESS NAMEn, sm AO /5 - fepn PHONE # ( ) 33 4/ - o17.3 V EXT. mo or MAILING ADDRESS 4/4 7/,e FAX $5 w # () 3.31Y - 63;? 2 CITY/1,4,A.4_ STATE ZIP 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 ansitkat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, and FE L laws. APPLICANT'S SIGNAT 1. DATE: PROPERTY / BUSINESS OWNE OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 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 rovided to me or my representative. TYPE OF SERVICE REQUESTED: ?0 0 I — / -C P 4 RE---14 11-{ Pe— / Ale i'-t 0 0 E c__ 4_A-5,..) ct - i eCe_____ COMMENTS: PAYMENT RECEIVED JUL 2 1 2009 SAN JOAQUIN COUNTY FNVIRC kl It, E PIT L ACCEPTED BY: cf) C 4_ 0 c_...t 44- EMPLOYEE #: a; 2,-( HEA-1-1RI )E ASSIGNED TO: 1--).---0 454 ---1----* EMPLOYEE #: & 2.-L3 DATE: 7/24 (ô 9 Date Service Completed (if already completed): SERVICE CODE: 5-2-Z-- PIE: Fee Amount: 1,2.1 0 , LA) Amount Paid &( t9 — DO ‘QUISCARD P*I e7 Payment Type t.v"--- Invoice # Chec r Received By: p_ EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003