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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# G SERVICE REQUEST# OWNER/OPERATOR /� C�nJO G IA,JIJi5c.c.14"' CHECK If BILLING ADDRESS FACILITY NAME SITE ADDRESS '7CSb/ '5r,4,16 Z4,715, ZW Lt,oCJ n/s' Z36 Stree[Number Direction Street Name CI Zi Cade HOME Or MAILING ADDRESS (If Different from Site Address) y��S f"/ i7j,.r A'+4 Street Number Street Name CITY 1 ,•,�jLc.J STATE (f�4 ZIP nl j 2 7G, PHONE#1 EXT. APN# LAND USE APPLICATION# (2-'1 ) 057- 3275' A_ /5— /38 WCO PHONE#2 EXT. SOS DISTRIc7 I LOCATION CODE C� CONTRACTOR/ SERVICE REQUESTOR REQUESTOR MtL T1 U I CHECK If BILLING ADDRESS l E BUSINESS NAME ;. J,y p' 1 PHONE# EXT' 1 LSI 33 -G6/3 HOME Or MAILING ADDRESSFAX# cc- v. ,3 K zI �J (w334— 07�3 CITY L Gird,' STATE C141 ZIP 9 j 241 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,STATE an.CLEEDERAL laws. APPLICANT'S SIGNATURE: G DATE: `0 PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ If APPLICANT i5 not the BILLING PARTY proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It is pfOwded to me or my representative. TYPE OF SERVICE REQUESTED: .5v2FA+:,; A-J S135-,Z,,C r tN^'rgn,.ti 4'%l w.i/W"rv�'�T �G•`� COMMENTS: SANj,O T p2701 / P�it711E7/c3.L� yE 1_HQE l MOON ACCEPTED BY: C EMPLOYEE#: DATE: O j ASSIGNED TO: �Scc7-C�t� EMPLOYEE#: DATE:10 Date Service Completed (It already completed): . SERVICE CODE: '�1 GJ PIE: '.: FeeAmount:.)W60 Amount Paid Payment Date Payment Type Invoice# Check# Received By: EHD 48-02-025 SR FORM(Golden Rod) 07/17/08