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W SAN JOAQ*COUNTY ENVIRONMENTAL HEA* DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # BUSINESS NAMEPHONE# V/ALTOr( EE2(-4 T 4 C , SERVICE REQUEST # 12ErAI.L FVt:L- .RC1t S ACCEPTED BY: G' L, �, �� r � 0U (-/s -.:?,5� OWNER! OPERATOR STATE C A ZIP q s6 9 EMPLOYEE #: S 3 0 [` A R E- M A-2 IC E -T -S CHECK if BILLING ADDRESS FACILITY NAME O r�iZ. E IM A, R (L E -4 3 S SERVICE CODE: j �� SITE ADDRESS E Fee Amount: Z7 is L 1 u E R D_ QU -r R- A, C 2 2Z US S Street Number Direction Check # 1 b S Street Name city Zip Code Different from Site Address) i HOME Or MAILING ADDRESS (If D'/ K T V 1 K ( C% S 2 E E T 2 S ` 0 & i Street Number Street Name CITY N Al U/N 2 STATE C A ZIP Y `l PHONE #'I EXT. APN # LAND USE APPLICATION # (.4;- 10 X32 - 5,}0 0 PHONE#2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR 11l t C N A E L W r� L �� CHECK If BILLING ADDRESSED BUSINESS NAMEPHONE# V/ALTOr( EE2(-4 T 4 C , COMMENTS: EXT. C) 3�-3—lrs2, HOME or MAILING ADDRESS p• O 1314 x /C 2 f ACCEPTED BY: G' L, �, �� r � FAX # ((�f (6 ) 3 4- it 4 - CITY t 1 O STATE C A ZIP q s6 9 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 FED RAL laws. APPLICANT'S SIGNATURE: DATE: 0 PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 121 C 0 p(T (Z, A«O f — 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: A -P( 2 t✓ V F- vJ t.0 COMMENTS: DEC 2 0 2005 SA NVOjAONM COU TY HEALTf 1 pEpARTTAL ACCEPTED BY: G' L, �, �� r � EMPLOYEE #: � 3 �-% DATE: ASSIGNED TO: W 1 L L t4 (,, EMPLOYEE #: S 3 DATE: ( Z. / L6 / Li S —1E Date Service Completed (if already completed): SERVICE CODE: j �� P : �3 0 Fee Amount: Z7 is Amount Paid QU Payment Date 2 2Z US Payment Type r Invoice # Check # 1 b S Received By: t� C< EHD 48-02-025 SR FORM (Golden Rod)