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SAN JOAQUIv ',OUNTY ENVIRONMENTAL HEALT" nEPARTMENT SERVICE REQUEST Type of Business or Property 1 FACILITY ID # SERVICE REQUEST # oo 6 2.<s7 OWNER! OPERATOR CHECK if e' e: M 4- i•A__ BILLING ADDRES-, --0 -e—g-,..-L.— ,.! FACILITY NAME /.., 141-A 1-)04x. a--.a.,-- SITE ADDRESS 4- 6_,,_ 4./5--to Street Number Direction Street Name C,1 Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number / ,, ,-4-1,1--(---4- Street Name CITY STATE ZIP PHONE #1 EXT. (qz4--- '/z-'-o APN # LAND USE APPLICATION # PHONE #2 EXT. ko k BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME 1 PHA( E # (74 Exr. Z--5-1 ((f I 32Z- HOME or MAILING rEal, y- r, 5— 2_, "L 1 72—e_ ce, 1 fAX # c, ii-o_e____ q 6/51.. ) 9Z 5---- ea 7.- 7 a z- 0 CITY 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 cation and that the work to be performed will be done in accorda ce with all SAN JOAQUIN COUNTY Ordinance Codes, Standard STA E and EDERAL laws. Ce. e 7 APPLIGSIGNATURE: DATE: ct PROPERTi / BUSirESS OWNER OPERATOR! MAN ER 0 OTHER AUTHORIZED AGENT 0 APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZA ON 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 thb SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me p1 my representative. TYPE OF SERVICE FaQUESTED: VG(?) :i PAYMENT COMMENTS:" RECEIVED MAY 20 2011 \ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ACCEPTED BY: Le)14)6 EMPLOYEE #: q 051 DATE: ,S7.10% It ASSIGNED TO: pe.-.1) /1"frz-A- EMPLOYEE #: 6,24 3 DATE: Date Service Completed (if already completed): SERVICE CODE: 512_ P/ E: ..e Fee Amount: Ai7l..(pi 6 Amount Paid c,,f / - 7 • .0-1, Payment Date ,6—/R .1.( Payment Type 7 Invoice # Check #(.= Re eived y: EHD 48-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)