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SADLJOAQUIN COUNTY ENVIR(NMENTAL HEALTH DEPARTMENT SERVICE REQUEST ' Type of Business or Property FACILITY ID# SERVICE REQUEST# 4(7gzntt7Vi2A i2 c)'5/�2 l—�S OWNER I OPERATOR AC=A FA In/[ LI1W/TE D IA/ZT E UL /ND, CHECK If BILLING AODRE55� FACILITY NAME NAEIZ R/r! n'` //�� SITE ADDRESS /-787/ �NF Tem T?Z9AD E5i CAGOn/ %S3'LC7 Street Number Direction Street Name Ci Zi Code HOME or MAILING ADDRESS (If Different from Site Address) .0 - 80K 107& Street Number Street Name CITY STATE ZIP W551- MEAITV C'A 5 9 PHONE#1 Ex . APN# LAND USE APPLICATION# 1W 37 2 - 55 -;20 3 -aoo - 05 ,-v/ PHONE#2 EXT. BOS DISTRICT LOCATION CODE an s -02 170 � CONTRACTOR/ SERVICE REQUESTOR ^`/ REQUESTOR N/V C�Y1 j�SNE�Z CHECK if BILLING ADDRESS BUSINESS NAME0 „r5/. IE (�^ A1.J fu L W PHONES �/ !/ L ExT' HOME or MAILING ADDRESS V FAx# ri F0 ' ( ) 66 2-j;'fe CITY QLD STATE A 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, A and FEO aws. APPLICANT'S SIGNATURE: DATE: -O PROPERTY/BUstNEss OWNER 13 OPERATOR/ ANAGER ❑ HER AUTHORIZED AGENT IfAPPLtCANT 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 infbnnation 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. TYPE OF SERVICE REQUESTED: SURF CE 2F CO/vT T ✓lEW COMMENTS: IJ�2t �, /1e,.. - � 6D ��- RECEIVED JUL 6 2007 -sa "." " i SAN JOAQUIN COUNTY ENVIRONMENTAL L ACCEPTED BY: t✓�t�� EMPLOYEE#: 622-1 DATE: -711-69-7 ASSIGNED TO: —FAS L ADD it LU-- EMPLOYEE#: [c-o--�5` DATE: 07 Date Service Completed (if already completed): I SERVICE CODE: 3(S PIE: �(j3 Fee Amoun . 'j p_ 'ri I Amount Paid g 1 (i LrL% Payment Date 1, O I Payment Type Invoice# Check# a.�� Received By: %L EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003