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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT S'S-ZED SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # 3(a) C 3 --/Q S-1 OWNER! OPERATOR CHECK if BILLING ADDRESS FACILITY NAME ^V.) e _;z:, -{- Tc., ,.e__. 's...a.c. N.c-‘v-. akg - SITE ADDRESS , Street Number Direction A). r...ti E Sir Street Name City Zip Code HOME or MAILING ADDRESS (If Different from Site Address) Street Number 1..1 e :L-'-' -r--\--,T4-tleet Name USItir CITY , STATE ZIP .S k c., C.-A'. kc. (1 C..11 9,C -2- \ '--• PHONE #1 Exr. (1cA 41-3 - S141,6, APN # VI if ^ OSO -30 LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT 2— LOCATION CODE i CONTRACTOR / SERVICE REQUESTOR REQUESTOR CHECK if BILLING ADDRESS BUSINESS NAME .i -3 (5\--ieN c...,-Aes- ',Th.\ N \At PHONE # ( i-L>k ) EXT. HOME or MAILING ADDRESS i\A FAx# (2&) _S 45..2 44 ,1 K 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 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 0 OPERATOR / liVI-srAGER 0 OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required C.,tYrAreAL s't 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 providedjo me or my representative. TYPE 0 EQUESTED: E - k £-A--77f pg- .... -A-1 0 e9 (._ P-i 6 f-4 &-c- ComniEt.,... -.. ......4 .,(. `'It °T. 4 z i'• SAN PIATtl PAYMENT RECEIVED MAY -7 2009 JOAQUIN COUNT,/ ENVIRONMF3ITL DS 61/ AITCEPTED BY: C.) C Lte ( f&---14- EMPLOYEE #: 0 S z.." ASSIGNED TO: cA__.12.1...zi_je._- _c c _e3, EMPLOYEE #: 0 Lf v-7 DATE: Date Service Completed (if already completed): SERVICE CODE: 5--2_2 PIE: se6,0 2._ Fee Amount: 4-,...1 0 , vo Amount Paid -). V () — Payment Date 50/0 0\ Payment Type _..-----. Invoice # Check # 3 0 1 g--- Received Bycy-G-- SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003