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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER OPERATOR r� A w w GIRO 2A AA K &qR xA 5 At A14A rr1 An �'/'1,r' ECK If BILLING ADDRESS FACItItt NAME (14efZD G(RANAJC PARICA514 SITEADDRESS /42/5- V/ �IRA.VT L/NE RD. 777A -15304 Street Number Dl'.cN.n `-/ StreetName Cit/ Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) IdEgrAp. Street Number Street Name CIN STATE ZIP G CAA 530 PHONE#t RAEXT. APN# LAND USE APPLICAnON1t_ ( 70Z) -7-07-0347 ' 3 P - i000a/ PHONE#2 EZT. BOS DISTRICT LOCATION CODE ( I CONTRACTOR/ SERVICE REQUESTOR REQUESTOR DON L GSIV� CHECK if BILLING ADDRESS BUSINESS NAME PHONE If EXT. ROVOST I ' ITCHA N GILT/NC 2 p HOME Or MAILING ADDRESS FAX# .4701 SiSK ume Ioz ( ) CIN E To STATE CA ZIP 5356 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. 1 also certify that I have prepared[his app ' tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, A E and FEDE taws. APPLICANT'S SIGNATURE: DATE. PROPERTY/BUST NESS OWNER OPERATOR/N ANACER ❑ THER AUTHORIZED AGENT 1fAPPL1CANT iS not rhe BLLLINGPARTY 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. TYPEOF SERVICE REQUESTED:A pggwpum N/reA-rE A l.J le. e e1i/TAa/e/ LANGNteK AEVIrkI COMME/I/{QtS: *44/1 / 1 p/t/ lL F� /t i R(t//'L��'�1/.(i• Afo/" i1T?ai',r//! ,h��, e OCT - 3 2012 / /!✓7tC �' a MN JOAQUIN vIre,lew- COUNTY LWRONMEWTAL / HEALTH ot'rrAmmrtExr ACCEPTED BY: EMPLOYEE#: DATE: ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: If Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM Golden Rod REVISED 11/17/2003 ( )