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SAN JOAQI 7:0UNTY ENVIRONMENTAL HEAL1 EPARTMENT lkoo SERVICE REQUEST Type of Business or ProAerty crry_e_ FACILITY ID # 0 0 2 7 (/ I SERVICE REQUEST # r ( i , 6 (607_ 5i-1 /4-j ‘Y-- OWNER / OPERATOR / CHECK if le:_t i._ di -ic-sz 7.2.s I BILLING ADDRESS FAcury NAME cAs_..) .k_e_r_ c',., Street Number Direction SITE ADDRESS rfrieZ....r Street Name 4L'(-6 +---, City els 2 ( 67 Zip Code HOME or MAILING ADDRESS (If Different from Site Address) zy a 6 Street Number .7 La,..,v,, joc 2 ...„ rev o • Street Name CITY L., STATE c ,A. ZIP q) Li s.---- 33 PHONE #1 err. (e60 q I 6.-- 7 q 17 B APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR „-------- \ .f", 1A'‘. js CHECK if BILLING ADDRESS BUSINESS NAME 0 t.---\ 670D t 5 ra--- t - Teel 1 ( L 6, q - c c5741--r - i r HOME Or MAILING ADDRESS ( 2 ty .., 1 .. . .1 i 3 1 6. .s.i. v ( , . 1. . ( ( RA ti i c;v. F t.A, 2 2 5' I( q q 3 ( C 4 OW 54._ .c.,_ STATE cA zll. q S ) 23 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 a COUNTY Ordinance Codes, Standa APPLICANT'S SIGNATURE: PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGEU OTHER AUTHORIZED AGENT If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required tion and th t the work to be performed will be done in accordance with all SAN JOAQUIN L4AL laws. DATE: Ce- cr 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 • available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: U .6B - --L7k --i - NOAYMENT COMMENTS: 4177,n(tNIRECEIVEI-L) SEP 2 0 2010 SAN JOAQUIN COUNTY ENVIRONMENTAL ;EALTH DEPARTMENT % ACCEPTED #: (0 By: .--) y EMPLOYEE DATE: Z 646 ASSIGNED TO: PQ--, ? 74\ EMPLOYEE #: & z \ 3 DATE: l Date Service Completed (if already completed): SERVICE CODE: 6-22 _ P1E: 36,02_ Fee Amount: zi7 t- ci o Amount Paid up_.4 4 . 0 Payment Date Payment Type ,--- Invoice # Check # I 1. 0 Received By: EHD 48-02-025 SR FORM (Golden Rod) REVISED 11/17/2003