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SAN JOAQUIlr a &)UNTY ENVIRONMENTAL HEALTH . _ , ARTMENT SERVICE REQUEST Type of Business or Property �CI CHECK If ILLIN DORES FACILITY ID # SERVICE REQUEST # I)c,orf,mo BUSINESS NAME i�5fr/Jn ASSIGNED TO: _ C.� i�- I I 1 S�-()OS00�� OWNER / OPERATORCHECK Mes�-k �► HOME or MAILING ADDRESS5�' 00 2/�-�.- -�. /`%-� If BILLING ADDRESS ❑ FACILITY NAME L)O / U AI'•hrY1G.i Payment Type SrrE ADDRESS4-C42t�'O Check # 33 I l '4-C4Stnal Number DI cNo `'�� Ca Zip Coda HOME or MAILING ADDRESS (If DNferent from Site Address) Stmt Number Street Name CITY STATE ZIP PHONE#1 ( ) Err. APN # LAND USE APPLICATION# PHONE#2 ( ) EM• BOS DISTRICT LOCAPON CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR �CI CHECK If ILLIN DORES C. r'Ory /� U EMPLOYEE #: BUSINESS NAME i�5fr/Jn ASSIGNED TO: _ C.� i�- PHONE# En. S-37- v ooh Date Service Comple d (if already plated): .roe HOME or MAILING ADDRESS5�' 00 2/�-�.- -�. /`%-� PJI E: . FAx# 37 S� ( ).5 CITY STATE C4 zIP[3J----35 17 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, STA • an E ERAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY/ BUSINESS OWNER 13 PERATOR/MANAGER ❑ OTHER AUTHORIZED IJAPPLICANT is nor he BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, tht: 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 t0 the SAN JOAQUIN COUNTY ENVIRDNMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. PA V A A r N T TYPE OF SERVICE REQUESTED: RECEI V ED COMMENTS: MAR 2 8 2007 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE AR MENT ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: _ C.� i�- EMPLOYEE #: 3 DATE: '2 2 1'() V -) If Date Service Comple d (if already plated): SERNCE CODE: PJI E: . Fee Amount: Amount Paid (�l� CSO Payment Date 3/21/0 Payment Type Invoice # Check # 33 Received By: Z EHD 48.02-025 SR FORM (Golden Rod) REVISED 11/17/2003