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SAN JOAQUIP JUNTY ENVIRONMENTAL HEALTV ‘EPARTMENT SERVICE REQUEST Type of Business or Property H P F- FACILITY ID # SERVICE REQUEST # \ - 5 e-LV d;9 7 .'2? OWNER / OPERATOR A CHECK if BILLING ADDRESS FACILITY NAME Ate rcr, clo . SITE ADDRESS z 4 5 rn- 01 0 Si s ) Street Number 0 Direction City Zip Code Street Name HOME or MAILING ADDRESS (If Different from Site Address) q '.- in ri-261," ci i 3_ '405' Street Number 5-f-ex .j.---\-z it (Z4 Street Name c-- CIT STATE ZIP i 0 6/ 0 b 0 ve PHONE #1 EXT. (teft ) ?3 7 3 7Q APN# 7 s---s- - 4 2_ 0 —02— LAND USE APPLICATION # e PHONE #2 EXT. (2_0 g Y9-5--LS 2_ BOS DISTRICT / LOCAT7 CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR SOMe 61 S CI 4 a e CHECK if BILLING ADDRESS BUSINESS NAME PHONE# ( ) EXT. HOME or MAILING ADDRESS FAx # ( ) CITY 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 and that the work to be performed will be done in accordance with all SAN JOAQUIN CotiNTv Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER err S A ‘(c'VGa_ C, DATE: .5' OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 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 ENVIRONMENTAI 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: :IL-(- ) 0 43V sE i-4 t C-- t- E---• i Ai 71) E C7--/ 0 A-) COMMENTS: A .., \L.s:A - -\I., t\ ck, C--C, s",.. , .„, ' ..,..., \ \ A ,c , Q PAYMENT ' RECEIVED MAY - 5 2010 SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH DERARTMEN ACCEPTED BY: (:),Li Lj E ( 0,et. EMPLOYEE #: 0 _-_S 24 DATE: 3--(sit 0 ASSIGNED TO: /\.4 ex; ,0 c EMPLOYEE #: f Lfra,e) DATE: 3-1 61 ( 0 Date Service Completed (if already completed): SERVICE CODE: 0 / PIE: / Co ta3 Fee Amount: t it-_cs 0--cp Amount Paid Payment Date Payment Type Invoice # Check # Received By: SR FORM (Golden Rod) EHD 48-02-025 REVISED 11/17/2003