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SAN JOAQU- 70UNTY ENVIRONMENTAL HEAL — DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # _5-e7 SERVICE REQUEST # SRM-4071c/ OWNER / OPERATOR CHECK if BILLING ADDRESS FACILITY NAME 1 SITE ADDRES /70 /.. Street Number Di ection Street Name City Zip Code HOME Of MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 EXT. APN # (4,o- 75 LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE 2- CONTRACTOR / SERVICE REQUESTOR REQUESTOR:7/ _--- ---,.?" /7/ k j / --in. /e CHECK if BILLING ADDRESS Q BUSINESS NAME (r) / PHONE # (6- 9 Ex-r. cf" HOME or MAILING ADDR S )----.3 7c 2--• (-7- v • FAX # ( ) CITY STATE ,,-- ( ...-A. ZIP .,7 ?--,,zy, 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 FEDE HAWS. • APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 54— DATE: 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 provided to me or my representative. TYPE OF SERVICE REQUESTED: /2_ c f-{ E.tl- c--T-)-( /'t .4—.) C-- t-1 Ec — /Q-C .-Lt ottikwFNT COMMENTS: RECEIVED MAR 11 2009 SAN JOAQUIN COUNTY ENVIRONMENTAL BFALTI-1 DEPARTMENT ACCEPTED BY: Of_ t k...)& ( ti-) 4 EMPLOYEE #: 0 -a" DATE: ASSIGNED TO: A 0 1, 6,....e. EMPLOYEE #: c ) ( t...( ? DATE: 3 /ft (09, Date Service Completed (if already completed): SERVICE CODE: .5-2 2_ P/E: 3(c,ci a_ Fee Amount: 41 _2., i Gs c7.1) Amount Paid p, k 0 Payment Date / k k i 6 9 Payment Type v---- Invoice # Check # .; (6 9 S Received By: 1,,pcs_ SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003