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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# I-AndA I 1 39- A4- 000e{ s'2g07o is 96 OWNER/9PERATOR (7Q vim Duel - N bllG 1 )or" I\e ,f . obi 1 ��I�'�CHECKIfBILLINGADDRESS� FACILITY NAME r_ I ( �a Ile) �� j'J (� I SITEADDRESS Q(f N 4rtJa ver1� Poad 4 nd� Pq Sa 3 1P Street Number D a tom- i Code HOME or MAILING ADDRESS (If Different from Site Address) /n�O G . /A2 el-�or� five h✓2-,, Street Number Street Name CITY Svc r _ _Irl STATE CIO Zip C�So2D S PHONE#1 EXT. APN# LAND USE APPLICATION# QD h L4(o S- 36 te 1%0 093 yyooa 1VP3Q q Is I Up 13q5 PHONE#2 Exr. BOS DISTRICT LOCATION CODE ( ) 'DOLl I q CONTRACTOR/SERVICE REQUESTOR REQUESTOR / �jy rn Q•,a�Q r/�r-� CHECK if BILLING ADDRESS BUSINESS NAME "t lJ N PHONE ExT n oa vin v - PWD Solid k,1as�-� LI(n�= 3040G HOME or MAILING ADDRESS FAX# l v 144 2,lin gvtou-e-, ohq ) y(og= 30--7 2' CITY ebCk+0 n STATE C44 ZIP l 50La5 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 aws (� APPLICANT'S SIGNATURE: DATE: Z 3— J PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT LA Sir• Sb I t d kA 84-e-, ing i n-eer 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. 1 TYPE OF SERVICE REQUESTED: a i l t i n -Pe 4-m 1 kh t 4 e C^)')c)"s COMMENTS: .70 l nS4al (a-hon D* o m-e, ri-w 9 rvvv,d i,t a 4e r- mohl4bri no we-(I No-6) on -'114e, soLkVl.easf sides 0 -'he- l�nd1�ll. ACCEPTED BY: 0*7W4 q J u��%�; �� EMPLOYEE#: 8 d DATE: ASSIGNED TO: � ,lc�d�3o��i 1,,,� EMPLOYEE#: -e7t6pa DATE: /1-1-31js-- Date Service Completed (if already completed): SERVICE CODE: 3 P I E: Z//`0 7 Fee Amount: 3 4b Amount Paid f je/'a GD//dA Payment Date 4;Z&-/i0/-?/i y Payment Type S'S Invoice# CChec`k#'. ,/ Received By: LQ EHD 48-02-025 �`��S �d dzr'Y � '�`�'�`'`'` '4�,0'' '7` W-6 SR FORM(Golden Rod) REVISED 11/17/2003 /4/CS_ sur 0-le A4' P. i jam— ©�,f-�e fY�b�.� � �'�,(,ea�+� &-f -" Lr/—6 ��g AJ