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r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# OWNER/ OPERATOR Ed Nlcolay CHECK If BILLING ADDRESS Ll FACILITY NAME _ 1 'U56I SITE ADDRESS 14539E l Loouise Avenue Ripon 95366 Street Number Ira an I Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) 14551 E Louise Avenue, Ripon, CA Street Number Street Name CITY STATE ZIP PHONE#1 EXT. 'API# LA D USE APP KATION# . ' r (209) 239 8995 0 1 7 NL}'— 0 0 3 7Z (NLS PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR/-SERVICE REQUESTOR REQUESTOR James Robinson CHECK If BILLING ADDRESS X BUSINESS NAME PHONE# Exr. JR Squared Consulting, Inc. 209 772-3841 HOME or MAILING ADDRESS FAx# 6532 Mcneil Court ( ) CITY Valley Springs STATE CA zIP 95252 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 my business as identified on this form. 1 also certify that I have prepared this ap ation an at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes$tandards �AJE and ERAL laws. `/ APPLICANT'S SIGNATURE: DATE: I Z d 25 PROPERTY/BUSINESS OWNER RATOR/MANAGER O THER AUTHORIZED AGENT IfAPPLICANT is not the VLLING PARTY roof of authoriZation to sign is required Title AUTHORIZATION TO RELEASE INFORMATMII1T: 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 environmentat/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. TYPE OF SERVICE REQUESTED: 3orfPAYMENT COMMENTS: 'S n �/i"[rn _,-ir�et� VED l(3Irq ck - DEC 12 2008 'I 'SAN JOAQUIN COUNTY ENVIRONHEALTH DEPARTMENT ARTMENT ACCEPTED BY: es L-V EMPLOYEE#: !l(f DATE: 1 )y ASSIGNED TO: S `U J / EMPLOYEE#: lJ DATE: Date Service Completed (if already completed): SERVICE CODE: LZ PIE: 2-60 Fee Amount: a( 0 Amount Paid 11 0 _ Payment Date 12 j I z-I O r Payment Type v'" Invoice# Check# p Received By: (16 EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003