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(APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 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. SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST ( Type of Business A 1 0 r or Property -k flO I A 1 V : Oct 5 FACILITY ID # -ci ci/Pi•i, ot SERVICE REQUEST # (2--CC3 -1 2-X cl 1 OWNER! OPERATOR, 44041 -'o;,1 l- \Ell CHECK if BILLING ADDRESS 0 FACILITY NAME SITE ADDRESS ,1 AS . 'Street Iiber Direction reel 1 i P r; vicis „ r V. t.- Name • - S)--ck. to kl ity 15217 Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Street Name CITY STATE ZIP PHONE #1 Exr. ( ) APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR , ir CHECK if BILLING ADDRESS REQUESTOR 8 5 1) s fL. jo 1 pigs is e BUSINESS NAME R V.e tri_s Pool a 3 IC "•i y EXT. PHONE # (2,,y)c,ca- r-1 3 HOME or MAILING ADDRESS 1 c06 Ai. Frohl-K9e Rd. FAX # ( ) CITY ,a , D n , r o Y‘. STATE (4 zip qs36 r.:, ...... BILLING ACKNOWLEDGEMENT: I, the undersigned property or business own.:r, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Of at'vity 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, STAE and FEDERAL laws. Azt\d' TYPE OF SERVICE REQUESTED: c( ,r- R o nincc, 1:, P \ck-v) C.---VaCt--- PPkitiliel‘ 4 i 5D V IN COMMENTS: ,. ult,i C004- Ao 30 S Q A` biliata AL' ovq-OuriscokriE. Vit-IS'Ll" " ACCEPTED BY: (-7 ,......... EMPLOYEE #: DATE: Ci, ASSIGNED TO: y.„...A.,--a7 ci EMPLOYEE #: DATE:c-,-.) . -,D_ 1 — Date Service Completed (if already completed): Date 1 SERVICE CODE: 1----- D )......, P/E: •-ti.po Ds_ Fee Amount: Aco--- Amount Paid .p.40. cp c7 Payment Date , / 3 f, C Payment Type C. V....._ , Invoice # .L.. heck # (.9 ca 7 s-3 Received By: EHD 48-02-025 07/17/08 e it Q ite k \--AA Ce de‘i(c0 z 4c, SR FpRM (Golden Rod) 4\_tAw. ,),14