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SAN JOAQL. iOUNTY ENVIRONMENTAL HEALTy ;EPARTMENT v �y SERVICE REQUEST Type of Business or Property if BILLING ADDRESSEr Octoc FACILITY ID # t, -EHEC SERVICE REQUEST # ick( ,.\ PHONE# EXT. A4fU� JUN 14 �OiO ENVIRONMENT HEALTH RERMJT/SERVICES S4 C'&c' ,,—I f .A u C OWNER/ OPERATOR CITY L� r .� r.` }U STATE LP S- Date Service Completed (if already completed): CHECK If BILLING ADDRESS FACILITY NAME PIE: 02 Fee Amount: - Z3 D . Amount Paid 45,230 p Payment Date6 Payment Type SITE ADDRESS '; o - CC-� " UL/(<' Street Num Gar Drection �l t � R. R IN Zi Cotle HOME Or MAILING ADDRESS (if Different from Site Address) Street Number Street Na.. CITY STATE ZIP PHONE til EXT' APN # LAND USE APPLICATION # (2cl I ' `1- y(C. 2-32-- 0 70 - oZ PHONE #2 EXT• BOB DISTRICT C LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTO r W if BILLING ADDRESSEr Octoc C 1 eN t, -EHEC BUSINESS NAME COMMENTS:L' e�, �_ � h y i S L PHONE# EXT. A4fU� JUN 14 �OiO ENVIRONMENT HEALTH RERMJT/SERVICES ACCEPTED BY: ®� U ( HOME or MAILING ADDRESS FAX# u C (4110) '3k$ - 1 CITY L� r .� r.` }U STATE LP S- 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 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: DATE: ,/�' lo PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 63 ( Q 6-ltl'UE A'.,5 (un;Aj '.Axw /fAPPWcANT is not the BILLING PAR proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: COMMENTS:L' e�, �_ � h y i S L A4fU� JUN 14 �OiO ENVIRONMENT HEALTH RERMJT/SERVICES ACCEPTED BY: ®� U ( EMPLOYEE #: DATE: /_ / r 0 I/Q ASSIGNEDTO: P.Dz A EMPLOYEE#: �[!/� DATE: i2 / Date Service Completed (if already completed): SERMCE CODE: CJ' -Z2 PIE: 02 Fee Amount: - Z3 D . Amount Paid 45,230 p Payment Date6 Payment Type Invoice # Check # Received By: J EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/1712003