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Apr 12 13 08:59a Mid Valley Consulting 530-749-9892 p.3 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Properly FACILITY ID # CNECK 81LUNG SERVICE REQUEST # FP�ftoiL-- BUSINESS NAM//� NA!!,, PHONE0 L �l!?, f * .% %l .�✓�.,f��il• .jam ?�l�• 6 HomE or MAa.ING ADDRESS rfes} / 411? /4)7?011 /1 J/1 / OWNER I OPERATOR ) �) ! f-1 ('� / R•,J SERViCE CODE: /rel CrrFC�cif Bi o Aon s5❑ FAciurr NAME ---, Payment Date Payment Type Invoice # SiTE ADDRESS ' �9leat Received By: JStreeterne 4 CCL'`t r l N ber [itrectianN HoMEor MAILING ADDRESS (If Different from Site Address) Street Number Street Narme CITY STATE Z p PHONE $1 APN t1 LANO UsE AI'PUCATIOId lF PHONE #2 E"r' 130S DISTRICT LaCArian Cone ( � o CONTRACTOR / SERVICE REQUESTOR REOUESTO� )/Zl CNECK 81LUNG ivf f S If ADEMESS❑ BUSINESS NAM//� NA!!,, PHONE0 r t a_ �� �l!?, f * .% %l .�✓�.,f��il• .jam ?�l�• 6 HomE or MAa.ING ADDRESS rfes} / 411? /4)7?011 /1 J/1 / FAxI ( 1 SERViCE CODE: /rel CITY k L STATE �' 1I ZJP 3— BILLING BILLING ACKNOWLEDGEMENT; I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENV7RONMENI'AL HEALT]I 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 JOAQUrN COUNTY Or&nance Codes, Standards, ST.aTE and FEDERAL laws. APPLICAI\"T'S SIGNATURE: _ °'% � DATE: PROPERTY I BUSINESS OWNIRR I] OPERATOR I MANAGER L J 0rrHF t AUTHORlzEDD AGENT 0 lfAPPLICAAlT is net the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE R ORMATION: 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 ENv1RONMENTAL 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: tV r 6y Par COMMENTS: i4 :5110 LY Y I :SPR 1,' 'yyJGA rnr...._ EK'y7R hC T�4 . D�F�.S"o+rrl_Wr AGcEPTED BY:— A4. EMPLOYEE #: DATE: // /� ASSIGNEDTO: �r �d EmpLOYEE#: DATE: q � Date Service Completed (if already cornpfefed): SERViCE CODE: /rel P l E: F, Fee Amount:,3 76O -D Amount Paid ---, Payment Date Payment Type Invoice # Check # Received By: EHO 48-02-025 REYSED 11117x2003 Received Time—Apr. 12._2011_ HlAM_No. SR FORM (Golden Rod)