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SAN JOAQUIN -OUNTY ENVIRONMENTAL HEALTI.1—EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# DkiP-X FAC IL- iT SSW 3E6)25 OWNER/OPERATOR CHECK If BILLING ADDRESS LFEn/ 4 t D PAU L A e 'AJAIViQZ FACILITY NAME Ve N,4 vew G( t SITE ADDRESS Q L-pD 1 9� Z,¢ 2 2 Z 4 ll?OND A A D Street Number Direction Street Name city Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE#11 EXT. APN# LAND USE APPLICATION# (zoy ) 3�s3- 278 oi - oso-oe P� - o - i PHONE#T Ex,. BOS DISTRICT LOCATION CODE ( ) 49o - 7S 7/ CONTRACTOR / SERVICE REQUESTOR REQUESTOR _ CHECK If BILLING ADDRESS BUSINESS NAME (' PHONE# EXT. HOME or MAILING ADDRESS FAX# . 0 . Z5 0K CITY u R L K STATE 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 nd that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards, STATE d LDE APPLICANT'S SIGNATURE: DATE: 57-17- C.2 4 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OT AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY,proof of authori ation 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. TYPE OF SERVICE REQUESTED:fo ld Sal<rA4pit IT4, IV TRATE L0.4D/N /" Nu E MA lV44,C116tVS ReV fit/ COMMENTS: CEIVED l� ��~ 1 MAY 7 200� ,, 4 leA- ,, 6U / ACCEPTED BY: 0(-I U-r- t 4e-A EMPLOYEE#: o3 -2—( ENI W I"�'/L ASSIGNED TO: O I� S EMPLOYEE#: G/ Lf f�TZ Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: 9 Lf(oS,oc? Amount Pai `p� Payment Date � -1 Payment Type Invoice# Check# /'?S-)1 Received By:X ' EHD 48-02-025 ` /LD(1 .J SR FORM(Golden REVISED 11/17/2003