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SAN JOAQAWUNTY ENVIRONMENTAL HEALTAWARTMENT SERVICE REQUEST Type of Business or Property CHECK if BILLING ADDRESS FACILITY ID # c'- SERVICE REQUEST # CAIZb Loc1t' 2 4 2009 FAX # F, - 0 l®zS OWNER / OPERATOR CITY C rL ^ CHECK if BILLING ADDRESS K4 E, L- � 0 1L (?/� R a L E vim^ r FACILITY NAME A rt5� A O / SAN JOAOUIN M N SITE ADDRESS I {M O F F G,T -9(-v'0 �" L l (� VA A -W-6 C A, '7,5- 3 3 b 'I a3 Street Number Direction EMPLOYEE #: Z (F: (.'' Street Name Date Service Completed (if already Completed): city Zip Code HOME or MAILING ADDRESS (if Different from Site Address) PIE: '13us- Fee Amount: C x �- :� ( 'l/ -4- Street Number 3 -- Street Name CITY c S i o (L +-09s Payment Type STATE C x ZIP 9 L PHONE #1 EXT• APN # LAND USE APPLICATION # (5-30) 7�S'- O`i9 ( 2�(-15C--�L PHONE #2 EXT. BOS DISTRICT Loc!7 CODE CONTRACTOR / SERVICE REQUESTOR REQUESTORA (C 64 X-& t, ' , / (/V G CHECK if BILLING ADDRESS BUSINESS NAME/ W P, ( 6Tf Ct ►cE�2��cr, c'- PHONE # EXT. 4 3:3 - /t rz_ HOME or MAILING ADDRESS 2 4 2009 FAX # F, - 0 l®zS (C/t6)3}3[I}L CITY C rL ^ STATE C 4, ZIP S-6 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 and EDERAL laws. APPLICANT'S SIGNATURE: DATE: /Z 3 %b 4 PROPERTY /BUSINESS OWNER❑ OPERATOR /MANAGER b OTHER AUTHORIZED AGENT �I C�(ZA'(JC 02_ If APPLICANT is not the BILLING PART1% 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. C.( -.S' -F- t 7 -'V9 --c F- ('-f — TYPE OF SERVICE REQUESTED: �► t COMMENTS: 2 4 2009 FEg GOUNv SAN JOAOUIN M N DEPAR N� ACCEPTED BY: �" L l (� EMPLOYEE #: C �� ATE: �^ ASSIGNED TO: �� EMPLOYEE #: Z (F: (.'' DATE: n , Date Service Completed (if already Completed): SERVICE CODE: l Ct's1 PIE: '13us- Fee Amount: _3 f S ��; Amount Paid 3 -- Payment Date ✓7_� �. �� j Payment Type l j Invoice # Check # h S 5 U Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003