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SAN JOAQU_ _:OUNTY ENVIRONMENTAL HEALTH DE_ _ -RTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # OWNER / OPERATOR , NP\C-\\4K C CHECK if BILLING ADDRESS FACILITY NAME —s • N(\,\,c-- SITE ADDRESS ‘‘1.4.Lk Street Number Direction SI- ••\.) "---<-- Street Name ''..-\)--C' \o--"..._ City Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 1 L \ --5L\ Lk Q'' ---WW7\e"-cl ca1/4e-1/44`,C9• k‘l-e-•<'street Number Street Name Cm( STATE PHONE #1 EXT. (267 4t) COCY1 - 3 l 9 ci APN # I LAND USE APPLICATION # PHONE #2 EXT. (2/5,66 CI (II BOS DISTRICT LOCATION CODE CONTRACTOR! SERVICE REQUESTOR REQUESTOR ' 5 C._3 CHECK if BILLING ADDRESS CI BUSINESS NAME PHONE # (7tq (t 2-0 --I -3( I q xE r. HOME or MAILING ADDRESS, 1 4 -.1-1q tA) 4:77 {.e41 l'.(C-1-411C1 Rt v e-,c -(3) k-kg-- FAX # ( I CITY S-4,5) cledv vt 6., Pei- ei 6" trz t q STATE ZIP 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 perfor will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standar DATE: - PROPERTY! BUSINESS OWNER 0 OPERATOR/MANAGER a OTHER Arm° ZED AGENT 0 ,41 t ik- 9 er If APPLICANT is not the BILLING PARTY, proof of authorization to sign 's required e 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: ,, 6---g t_q COMMENTS: I ( ACCEPTED BY: COLAA/L.A.J2,.„--rt-A, EMPLOYEE #: 01 6, 7 DATE: ...$2...._..... ASSIGNED TO: r) , , _ EMPLOYEE #: te -2 ( DATE: 4,77 7- Date Service Completed (if already completed): SERVICE CODE: C1-2,:z...„ P / E: 'tzi_i_i_j_. — Payment Date 1/2-4 j / 1 Fee Amount: ,-2_,1 t_t — Amount Paid Payment Type Vi csa, Invoice # Check # Received By: EHD 48-02-02 11°6'92-9 REVISED 11/17/2003 C ,) Ct.k4"2-C ','kE 2ci SR FORM (Golden Rod) PAYMENT RECEIVED JUL 29 2011 SAN JOAQUIN COUNTY EN HEAL-ruVIR°NMENTAi - DEPARTMENT ATE andt:is1 FM/AL 1 WS. n1) APPLICANT'S SIGNATURE: — /