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11/30/2004 11:53 2094683433 FIFTH FLOOR SAN JOAQL1N *NTY ENVIRONMENTAL HEALTH ` SERVICE REQUEST Type of 3usiness or Property FACILITY ID 4 la o -S SAo' *\Oil OWNER I OPERATOR il)p / FAsa rrr NAME A'1 ryi fl m SITE LUDRESS I U � I {' W lrrecY1 Or'Z'}- HOME or MAILING ADDRESS (If Different from Site Address) CITY L A Po-` rn 0. PHONE #1 APN # �(SCX)) a-7a-Cp3LA°� PHONE #2 EXT. PAGE 02 5 bLl0b CHECK If I S�ocK �n I95ao3 Zia ZIP gcxaaa LAND USE APPLICATION # SOS DISTRICT II LOCATION CODF- CONTRACTOR / SERVICE REOUESTOR REQUESTOR 7�4 � COMMENTS: ,neec, A -o 5 C-V)4cJucA CHECK if BILLING ADDRESS BUSINI;ss NAME er 1 t1L• PH�OyNE0 (y W. uACA0 HOME or MAILING ADDRESS 30 Cr% C) s he EMPLOYEE #: F3 7 -3 DATE'- ATE_Date FAX 9 c • l ) CITY STATE C-0- ZIP C r 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 DE'ARTmENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 1k 1 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 OrdKnaywe Codes, Standards, STATE and FEDERAL laws. APPLICAN'T'S SIGNATURE: `j e �g_ �)` 1�`� lwft: '17- -- -7 - 0 *4 PROPERTY / BUSINESS 0", Ek ❑ OPERATOR / MANAGER 13. OTHER AuTHORIzED AGENT Pf 1fAPP4rcANT is not the B1LLINGPAR proof of autharkalion to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: Wheu 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 environmentallsite assessment informmion to the SAN JOAQUIN COUNTY ENv>RONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sarne time it provided to me or my representative. TYPE OF SERVICE REQUESTED: (,CST E T e -o F t T - COMMENTS: ,neec, A -o 5 C-V)4cJucA ccNe-sA-- o-� -Tus \o 1 FiEcoVED DEC - 9 2004 nhnl IN COUNTY ACCEPTED BY: C% L t V i EMPLOYEE. #: 2-1VAM r- T ASSIGNED TO: G _S Q ,J EMPLOYEE #: F3 7 -3 DATE'- ATE_Date DateService Completed (if already completed): SERVICE CODE: P I E: Fee Amount-., Amount Paid. a� �• D Payment Date. - 0 1-aymant Type Invoice # check #I tf 1-7 Received By: EHD 48-02-025 SR FORM (GoldenR-�� J.1 REVISED I ill 712001 1+�"