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SAN JOAQU*COUNTY ENVIRONMENTAL HEALTAPARTMENT SERVICE REQUEST Type of Business or Property &asol ine Station FACILITY ID # p8 O 37t-7 SERVICE REQUEST # 5'L �, OWNER/ OPERATOR ,sem GNEVtZoN Pr1`I5P C -TS Co. CHECK If BILLING ADDRESS FACILITY NAME q q Imo► V CHECK If BILLING ADDRESS SITE ADDRESS 4344„ Street Number ` Direction �ater l od ROZtf Street Name PHONE # FAX# (a25) Sj'pG�C�'Dr1 Ci qS 2 t �j Zip Code HOME or MAILING ADDRESS (if Different from Site Address) Street NumberF Street Name CITY STATE ZIP PHONE#t EXT. APN # P / E: 2M LAND USE APPLICATION # PHONE #2 ExT• Payment Date `7 d BOS DISTRICT1[ LOCATION CODE BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator o authorized agent o 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 FEDERAL. laws. APPLICANT'S SIGNATURE: c« DATE: Z d4 PROPERTY/ BUSINESS OWNER ❑ OPE TOR AGER ❑ OTHER AUTHORIZED AGENT X Me-+ M:2nMelr' If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required dd 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: Re ra lr / SERVICE REQUESTOR RECE1v L�-v REQUESTOR Xa• z &i2n1nc5 , ioroj. !`ler. '$ 2� Jv� 2 COVN� SA FNviviot4 Mf S HEALTH OEPAR CHECK If BILLING ADDRESS BUSINESS NAME . R1 -1L Desmon Inc... PHONE # FAX# (a25) EXT._ 313 -17`01 HOME or MAILING ADDRESS 1340 Arnold Drive. Suite CITY r1artince STATE CA ZIP 11456 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator o authorized agent o 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 FEDERAL. laws. APPLICANT'S SIGNATURE: c« DATE: Z d4 PROPERTY/ BUSINESS OWNER ❑ OPE TOR AGER ❑ OTHER AUTHORIZED AGENT X Me-+ M:2nMelr' If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required dd 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: Re ra lr R t r0T 1 t ptan n 6he c k RECE1v L�-v COMMENTS: Plan check for Spill Containment �cpl�cet�►eh'i'. '$ 2� Jv� 2 COVN� SA FNviviot4 Mf S HEALTH OEPAR ACCEPTED BY:9. Von I -(Le.- EMPLOYEE #: $31-7 DATE: �f ASSIGNED TO: ::y. C, 6,-mJV EMPLOYEE #: 3 DATE: Date Service Completed (if already completed): SERVICE CODE: l P / E: 2M Fee Amount: 2 Amount Paid z 6 Payment Date `7 d Payment Type Invoice # Check # F-00 ((3 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003