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SAN JOAQUIi%",;OUNTY ENVIRONMEINTAL HEALf )EPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# L4 0 OWNER/OPERATOR I CHECK If BILLING ADDRESS® G £ W FA I�rt S FACILITY NAME SITE ADDRESS � (N/A/(j (—L(/L E TC'1 SZOG Street Number Direction Street Name ci Zi Code HOME or MAILING ADDRESS (if Different from Site Address) P.0 , Q6JC 754 Street Number Street Name CITY STATE Ca ZIP CLc:MEn/TS PHONE#t ExT. APN# LANDU PLICATION# SG q S f z7 Q Y� PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( ) CONTRACTOR / SERVICE REQUESTOR REQUESTOR 13,'1 ( t^j�tJ CHECK If BILLING ADDRESS BUSINESS NAME l PHONE# E'er' S/�(�FRtEI� c:AvG/tir;G-2in/4 TNc . (log ) %y3 - Zo2� HOME Or MAILING ADDRESS FAX# goys ("o2o/V4D v Av& (ZoR ) qY Z - O 2'l4 CITYL 7D6,1�TON STATE G /� ZIP 9S2U BILLLNG A7CKNOWLEDGENIENT: 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 and FEDERAL laws. APPLICANT'S SIGNATURE: 14 Z DATE: 9171, 4 PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT❑ If APPLICANT is not the BILLING PARTY,proof of authorization 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: . FA C-E C-%C� C_-o ti'T r� COMMENTS: ECE"'ED &SE? 7 2004 a0b Y- 1013-1 IEM � (0/')/� yv SAN JOAQUIN COUNTY l I" �EppN��VIRONMENTAL tH ACCEPTED BY: C)L i Et EMPLOYEE#: �j z TE:T - j(Q t ASSIGNED TO: �C� EMPLOYEE M 61 DATE: 9 W Date Service Completed (if already completed): SERVICE CODE: �I S P 1 E: 2G C`3 Fee Amount: �( Amount Paid �19L.60 Payment Date Z 0 Lf Payment Type t/ Invoice# Check# 7Sa Received By: ?� EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003