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SAN JOAOUI ,OUNTY ENVIRONMENTAL HEAL-i,..oDEPARTMENT SERVICE REQUEST Type Doff Business or Property FACILITY ID# SERVICE REQUEST# �/eSI G1 n* Y,-/ q OWNER/OPERATOR •�b�Grf ��//�► r,►! G `-4c/ ruerv:�R„ nnnoeee FAcu"NAME Gr �f NTE ADDRESS !� �. f ;a /(/Orrng,n �}�/•rZ k�� Street Number +Direction Street Name Ci Zi Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP NHONE RI ^' ANN 8 LAND USE APPLICA[ION iV L M .5, PHONE#2 ExT• BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE RE'QUESTOR CHECK if BILLING ADDRESS LJ BUSINESS NAME PHONE# 13/ ^ f HOME or MAILING ADDRESS FAX# S 35357_ So l4 rf 00,44 3/- 2 3r�7• CITY S f-0 c S�T�F� ZIP 9.5,- BILLING SBILLING 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 wtu oe outea to me or my ousutess as Iaentmea on uns iorm I also certify that I have prepared this appli • n and that the work to be rformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,S A and FE S. APPLICANT'S SIGNATURE: DATE: PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT GlvlL, ANG /Z If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 7Ytle 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, Reotechnical 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. TvDC nC Ceo,nre D�nneeren• `/ 1 Sd� /— / / s �(J COMMENTS: V.JIw 7 Ij iLNlEN, RICPUL RECEIVED MAY 2 4 2006 SAN JOAQUIN CO,UN�T�`+�(° ACCEPTED BY: /A- EMPLOYEE#: tiEAL fy{DEP 1 ,�I.y`&7 SU ASSIGNED TO: ` EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: A;;54. Fee Amount: /�� _ �� Amount Paid g" j �pz> Payment Date a / I Payment Type Invoice# Check#1_? Received By.