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SAN JOAQUIN 'OUNTY ENVIRONMENTAL HEALT*EPARTMENT SERVICE REQUEST Type of Business or Property Iv( Ob i' ( -e /4611'112_ rack.- FACILITY ID # :.Z. 3c9S- SERVICE REQUEST # SROC., (LC S—°63 OWNER / OPERATOR 1 CHECK if BILLING ADDRESS FACILITY NAME ft,f_.- I P /10131(.e. Z:--------S N-1—akS SITE ADDRESS ' 50 Street Number Direction 1 her C oke _ct_ C ,,,D Street Name $4-0 CAP ri CI Zip Code HOME or MAILING ADDRESS (If Different from Site Address) g6 1 1 Street Number Oeasa (i+ K 001 I Dr. Street Name CITY 3 STATE cal xi Z113 9 5-/ ye PHONE #1 EXT. ( Z/08 ) qqq- e / ,o I APN # LAND USE APPLICATION # PHONE #2 EXT. (2o') 9 I ,2 V3 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR --S-e.E.---Sot wv QI CHECK if BILLING ADDRESS BUSINESS NAME C 0 ut vvvf „s„ A ''. 7„., mos6, (e &-s, Fa 4.e ss PHONE # EXT. (/Q) Lo q - Li 2o ) I t HOME or MAILING ADDRESS / / 3(011 P(e_ackv\--i- IC rk_o I ( 1) ç. FAX # ? ) 5 , • 7 2 ? - I D 7 0 CITY SN a... vx 0.-ic; ._..Q_ STATE 04 ZIP c5/ ci so- CITY 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 FEDERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER d OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 IIAPPLICANT 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,gALTH DEPARTMENT as soon a5, it is available and at the same time it is provided to me or my representative. Oc 1 , TYPE OF SERVICE REQUESTED: 3 eC +L OIC\ 0 X 1,000 . I el V Iff/Yllen+ PAYIVIFNIT COMMENTS: RECEIVED JUL i 0 2012 SAN JOAQUIN COUNT ENVIRONM` EN HEALTH DEPAR ACCEPTED BY: 6, Li o ....._, iv_k_ EMPLOYEE #: DATE: ASSIGNED TO: p.e 4 10—A-2.---k EMPLOYEE #: DATE: -7 1 to Date Service Completed (if already completed): SERVICE CODE: .52_2_ P/E: 0 2_ _6.., Fee Amount: 4 .„25 -0 0-D Amount Paid 1625z), -0 0 Payment Date fir ia Payment Type t,./ Invoice # Check # I 9.9 k., Received By:---7 , ,-c (— EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003