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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID# SERVICE REQUEST# S I D-EN _I �Zc' oC4 OWNER/OPERATOR CHECK if BILLING ADDRESS❑ Y /Z rV LLC. FACILITY NAME A/�///1/ SITE ADDRESS I-1 - 6-7 �' �jTr�MP D� R�Q-17 LODI �ISZyO _1 Slreel Number Direction Street'NName Ci ZI CoLe HOME or MAILING ADDRESS (If Different from Site Address) n '/1 I 11 W V -?,-?,q E,4 -r 4 Street Number n 7 Street Name �f� CITY V r n 'n n_Ar STATE N ZIP -7ZLI-73 PHONE$1 Eai. APNa LAND USE NZ zip aoq) X115 —1 `130 0!q - 3yo - 13 Pro -oro-2L13 PHONE#2 Ezr. BOSDISTRICT �' LOCATIO<ODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR n `' 0 ^ CHECK if BILLING ADDRESS Ef Ea'' BUSINESS NAME PHDNE# � ( `�uN rF Mv2� Y Z�r 33y HOME or MAILING ADDRESS FAX# RO. Box 7.100 (Zoe ) 33K - 0723 Cm 0 o ( STATE CA ZIP 6152 t'! BILLING ACKNOWLEDGEMENT: 1, 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: --116 DATE: "t/� -2ol-1rro6�J PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ;C- C7(/J F- 1fAPPL/CANT is not lite BlLLl.NG 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 environmentaVsite assessment Information t0 the SAN JOAQUTN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time It is provided to me or my representta�tive. n— 11 TYPEOF SERVICE REQUESTED: TOIL-5 sui��-Br�i�Y RECD VE COMMENTS: S� j� SEP 2 , 2006 �,,c� /7'/i�`'J SAN JOAOJIM COUNTY JIFONMENTAL �7"�-117,114 HEALTH DEPARTMENT ACCEPTED BY: 0(_T V+E r fC-A EMPLOYEE#: Q3- Z1 DATE: ZZ- d6 ASSIGNED TO: /-- In6oi�l4- EMPLOYEE M Sq6 6 DATE: Zai 06 Date Service Completed (if already completed): SERVICE CODE: �L Z PIE: 1-4;,V/ Fee Amount: D i Amount Paid I 10. C) -D Payment Date Z'Z- C)b Payment Type �� Invoice# Check# N77( Received By: EHD 48-02-025 SR FORM(Golden Rod) REVISED 11/17/2003