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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property . /FACILITY ID # SERVICE REQUEST # (---, ) i ..-----7/, , OWNER / OPERATOK , ,i/a, a VA q //p3 CHECK if BILLING ADDRESS FACILITY NAME / i nOy J /41/d/vS. SITE ADDRESS 41- 474 /1.4Z-77.eetILber Direction :ekame — 5110(.4Det- City Zip Code HOME Or MAILING ADDRESS (If Different from Site Address Street Number Street Name C I Ty, 51/22 TATE ZI PHONE #1 EXT. APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR/ diA4-i(ii--c. ail( , .--- , alogs CHECK if BILLING ADDRESS BUSINESS NAME , / L it Ofh,p HONE # ( ) (Dti q --()1(eS7 EXT. HOME or MAILING ADD R,22,y2 ,I --, i7 l ( / i -7 FAX FAX # CITY 5/z 7 &6 iti (7,,,, STATE ZIP /5 2616 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 Of 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, 1 ATE and PEDE L laws. APPLICANT'S SIGNATURE: PROPERTY! BUSINESS OWNER Ur DATE: OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT IS ncit the BILLING PARTY proof of authorization to sign is required 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: .0' . .s...iv 'Ulla° II) SpeCIT/k- ReCinfEi COMMENTS: w jelit j Ex.ci avvf , 06ed 1 0 i oftlf2r-- au (-7 APR 24 20k SAN JOAQUIN ENVIROItim C°UN . HEALTh Dep ENTAL ARTmEN ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: P / E: - Fee Amount: 415 -2_, L.___-,:-,_ Amount Paid It. /a- -7 1 ,....i.e-- , ---- Payment Date 4(24, / 1 Payment Type allk . Invoice # Check # Received By: (4,5 , EHD 48-02-025 SR FORM (Golden Rod) 07/17/08