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I.OUNTYENV'RONMENTAL HEALTH DEPARTMENT Type of Business or Property SERVICE REQUEST V,4 C T co.?,�,��w FACILIT ID D# SERVICE REQUEST# �L 57y�r OWNER/OPERATOR /ITYN V/A10EKT u A f' D LoOuCA C L C FACILITY NAME CHECK If BILLING SITE ADDRESS /o 9G 7 �/ s7-/a7= eo6W7-F 99 WESrFzo/v � n Street Number Direction ri4L� 2�, �-G/p/ 95 Z 4rj HOME or MAILING ADDRESS (if Different from Site Address) Street Name D v 2329 cit zl code CITY Street Number Street Name APN# STATE _ PHONE#1 EXT. C—A ZIP 95Z4 ( L09) qf/ — 2303 LAND USE APPLICATION# PHONE#2 EXT. �s9 -/�o - 3 PA _07-35. (6,P)p� ( z ( ) 13 /% J O - C2060 BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR BUSINESS NAME boAJ / r /� --� /V yGf• CHECK If BILLING ADDRESS GHE57VECQjvs(� L j� - PHONE# EXr, HOME Or MAILING ADDRESS CITY -71, 2 L152c4 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 work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, S and FED a S. APPLICANT'S SIGNATURE: DATE; /O• PROPERTY/BUSINESSOwNER❑ OPERATOR MANAGER ❑ OTH AUTFIOHJzED AGENT 11 IfAPPLICANT is not the BILLING PARTY proof of authori tion 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 JOAQuTN 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: //1 TE LOp fo/c Su rrA-Rt 4/T S7-uD/1=S COMMENTS: RECEIVED M. r• �5�c�o �o 3DB OCT 2 9 2007 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE ACCEPTED BY: O 1 L 1 EMPLOYEE#: ((-1 3 -L� DATE: (V 2I Q ASSIGNED TO: E S C E+ I 9 EMPLOYEE#: C DATE: /-0 Date Service Completed (if already completed): SERVICE CODE: �– PIE: 2CoO Z Fee Amount:, c/>O c'i� Amount Paid C� UV Payment Date C)� '� Payment Type Invoice# Check# a11 % 7.— Received By: EHD 48-02-025 SR FORM(Golden Rod) ' �� REVISED 11/17/2003