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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# AERVICE REQUEST# / C& CP4 C--' ki SK W7902- OWNER/OPERATOR Cy , t 1 , E CHECK if BILLING ADDRESS Li FACILITY NAME 1K IN L A 4) r- VF,- 9t^ A L. -T E P I SITE ADDRESS 5_-? A- ' I A_;� �1. .�/�N%67Cq C C Street Number I Direction r Street Name C ity Zi Code HOME or MAILING ADDRESS (If Different from Site Address) J 9qel -7/Um' e Street Number Street Name CITY STATE zip S 4e C' 0 �► C �i �I S PHONE#1 EXT. APN# LAND USE APPLICATION# 6�cl 47&1 ^ 417,31 I/PHONE#2 EXT. BOS DISTRICT LOCATION CODE ( 70 - �� CONTRACTOR/ SERVICE REQUESTOR REQUESTOR 'SA CHECK if BILLING ADDRESS BUSINESS NAME PHONE# EXT. HOME or MAILING ADDRESS FAX# CITY 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 be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 1UC( ,Q 2 DATE: O �4� PROPERTY I BUSINESS OWNE PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El If APPLICANT i 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. TYPE OF SERVICE REQUESTED: Cu 11&4f eV0 AYMEN COMMENTS: RECEIVE VFW j �ktlrSh�i P NOV 2 6 201 V) SAN JOAQUIN COUNTY ENVIRONMENTA NT ACCEPTED BY: li wl EMPLOYEE#: DATE: i I rJl /S ASSIGNED TO: �Adai EMPLOYEE#: W DATE: f 1 Date Service Completed (if already completed): SERVICE CODE: PIE:' Fee Amoun .� 'W Amount Paid ts-�_ ,pp Payment Date Payment Type Invoice# Check# �� Received By: EHD 48-02-025 SR FORM(Golden Rod) 07/17/08 ig P.o11o11 -� fo S"