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• • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# RE,-rArIL FULL rAC `o6ti Skop S i & y;,- OWNER/OPERATOR ll t V S ro p VIA A'R-V—ET-r, CHECK If BILLING ADDRESS FACILITY NAME U I v— S 1--0 p 4 3-6 SITE ADDRESS S T Q ( ( l! Q V E S U C.(G Fro"4 r 0 Street Number Direction Street Name Ci Zi Code HOME or MAILING / P2 E ADDRESS (if Different from Site Address) E��T E(Z I S '7 ST- S"6 1- Street Number Street Name CITY F (LE 14A o I LT" STATE C ^ ZIP PHONE#1 EXT• APN# LAND USE APPLICATION# ( S'to) SoO PHONE#2 EXT. BOS DISTRICT LOCATION CODE CONTRACTOR/ SERVICE REQUESTOR REQUESTOR I C a A,e L W� � 1 o r'k CHECK If BILLING ADDRESS I1 BUSINESS NAME /V� PHONE# ExT' (/VRLTO ►-I FirlC,taF✓Gf2 r�tC. , htC- t4 2- 181sQ 1trL HOME or MAILING ADDRESS 7�` O p 0 'O Z FAX# r+� z. CITY t/�&S T- S 't'<a- br V,F- � STATE / 4 ZIP / S-6 q I 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 an4 that the work to be erformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and F DERAL la s. APPLICANT'S SIGNATURE: Y�4ADATE: Z l PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER OTHER AUTHORIZED AGENT I�f e� �)Z y-vI v-L— 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: F V ( FFM) COMMENTS: PAYIVI RECE /5.h SEP 5 2007 . ,SEP 0 5 '2007 SAN JOAQUIN COUN ENVIRONMENT N1;d1E- H'LALDi ACCEPTED BY: EMPLOYEE#: T/Q, r ASSIGNED TO: EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: P 1 E: Fee Amount: da Amount Paid '0,l Paymenf Date Q I�v7 Payment Type Invoice# Check# 3 g Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003