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MAR -07-2007 08:03 Seruice Station Systems 408 938 8888 P.03 SAN JOAQ*COUNTY ENVIRONMENTAL HEALTI' 4PARTMENT SERVICE REQUEST Type of Business or Property C�R,S WA tf FACILITY ID # I FT 000 CHECK If BILLING ADDRESS SERVICE REQUEST # S'�c u OWNER 1 OPERATOR PHDNE CHECK If BILLING-AU-MF,55© FAcwTY NAME V YL0 C- 0 - ( FAX qt) SITE ADDRESS RIC) ( Street Number Di -0i on � ) QV -C r. 6'"� ,(/Street I O "k- lName AN JOAC�UIN OU S�_. 4—k 1A `lC�it tq qa,( Q 7 1 HOME or MAILING ADDRESS (If Different from Site Address) Street Number, EMPLOYEE #: e e CITY SERVICE CODE: STATE Zip PHONE #1 EXT. (.boy)- I j,5q APN # //61200-2 J L LAND USE APPLICATION # PHONER EXT. 4.2 Payment Type 805 DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR i1 L"� s� CHECK If BILLING ADDRESS BUSINESS NAME �^ , lxc �o TJ,,_,e_tV Imo► -fD PHDNE E -T. HOME Or MAILING AD fO � � AVel FAX qt) CITY ;tom Voiz STATE 64 ZIP Q �I BILI..ING, 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 of 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'IOAQUTN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. � �j APPLICANT°S SIGNNrURE: � {A, `1-`}1/'-I�'. ��-� -- DATE' •Z �C/� � / PROPERTY / BUSINESS OWNER❑ OPERATOR /MANAGER ❑ OTHER AUTHORIZED A4rrNT V � ► If APPLICANT is not the BILLING PARTY, proof of'authorization to sign is required T/lle AUTHORIZATION TO RELE.ASF I F Y2MATION: 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 environmcntal/site assessment information t0 the SAN ,JOAQliIN COUNTY ENVIRONMENTAL HEALTH DEPARTML-NT' as soon as it is available and at the Same time It i5 nrbvided to me Or mV representative. TYPE OF SERVICE REQUESTED: Uiig l� COMMENTS: � �Y7CACJO_W Skt/ �o TJ,,_,e_tV Imo► -fD I E MAR 0 6 �OOI n"y AN JOAC�UIN OU ACCEPTED B EMPLOYEE#: C DAT9 T A$SIC,NED TO: EMPLOYEE #: DATE: Date Service Completed (if already mpleted): SERVICE CODE: PIE: 0 Fee Amount: Amount Paid J L Payment Dated I I r 4.2 Payment Type Invoice # Check # ! z' Received By. EHD 48-02.025 SR FORM (Golden Rod) REVISED 11/17/2003 TOTAL P.03