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I also certify that I have prepared th• COUNTY Ordinance Codes, Stand SAN JOAQUIN COUNTY ENVIRONMENTAL HEALtti DEPARTMENT SERVICE REQUEST Type ofpusiness or Property FACILITY ID # ou 031 io SERVICE REQUEST # 5Roo , (0.2c1 OWNER! OPERATOR COt.) A-NAn • CHECK if BILLING ADDRESS FACILITY N AM E,..._ f—. 1 1.4 f\ C...C_t •PicV-R, v_ 7°p - SITEADDRESS 2_ Sco Street Number Direction vtreet Name L.---,--12A-C___ L..., City \ Zip Cod,, HOME or MAILING ADDRESS (If Different from Site Address) Z. SCO 1/3 Street Number k, f --,/6.Q, C..\ Street Name CITY STATE ZIP PHONE #1 EXT. PHONE faft ) 2:3 5-Cog APN # LAND USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE RE UESTOR REQUESTOR 01-ii\5 NJ ) e CHECK if BILLING ADDRESS BUSINESS N Am (- " F601. P 1,1-5-7--Q Tiu c___ PF4q$ ) 3-9'9 -,3 // 1 EXT. HOME or MAILING ADDRESS 770 \MA 5 4k\i FT, FAx# CITY Fi-,._ ziP 95-,G 6, BILLING ACKNOWVDGEISIENT: I, the undersigned property or business owner, operator or authorized agent of seine, acknowledge that all site and/or proje ecific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me, or my ess a identifieoion t form. APPLICANT'S SIGNATURE: era cation ,and Th TE and FED to be performed Will be-done in accordance with all SAN JOAQUIN DATE: Z -•.Z.0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAIREirU OTHER AUTHORIZED AGENT 11Ce9C.0 If APPLICANT is not the BILLING PAM', 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 JQAQUIN COUNTY ENVIRONYIENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Out_ se4 yk-( ,TyPE OF SERVICE REQUESTED: GV) eds pAYmENT, 'ImmmENTs: FthcEtvcv _ FEB 2 5 2°1 s,,ts4 JOAQUIN CA:21., ENVIR°NMENI-ro.0 i-it Ak- ACCEPTED BY. -------------74/Z----''-- EMPL OYEE #: n, 47 C.? DATE: ASSIGNED TO: \ t A. i po_71-1,--)Az......pr- EMPLOYEE #: 6.2 Z_ ( i DATE: Date Service Completed (if already completed): SERVICE CODE: c ---, --- - G-- 4.--- PIE: '36 0 7 Fee Amount: -T? ((.L e-1) Amount Paid -05 .2,4 (4, , 0 D Payment Date -912_5 (/ I Payment Type Type _ Invoice # Check # 55--j_. Received By: EFID 4e-02-025 REVISED 11/17/2003 SR FORM (Golden Rod)