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SAN JOACIlr COUNTY ENVIRONMENTAL HEALTIFEPARTMENT SERVICE REQUEST Type of Business or Property CO el Mt rCicl t FACILITY ID # SERVICE REQUEST # i t OWNER/OPERATOR 11 ,4rtN Covr 4-, LLC CHECK if W 6-1-COre BILLING ADDRESS ri FACILITY NAME SITE ADDRESS (621 Street Number Direction Arrhy GPf+ Street Name SA-o cf< fo A City q c 2. 06 Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Sac Street Number 1 L-11'11 S.Frtt.4- y i+e 3oo J Street Name CITY Oct(C iCtA STATE C,4 ZIP qq612. PHONE #1 EXT. (SIO )2,40 — c2 1-15 APN #LAND 163--34o -03 USE APPLICATION # PHONE #2 EXT. ( ) BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR I\ Uje,30 VciSciVt2. CHECK if BILLING ADDRESS E r BUSINESS NAME A \ . at 1 iv ilt f-- cm/ irc4401-ti-kk Cirouf j I n C. PHONE # (9 51 ) —736" S 33 4 EXT. HOME or MAILING ADDRESS 17 Ci p 141 l cliff-F.) S vi'-l-t 10 3 FAX # (q51)-736-756o CITY Co ram STATE c A. ZIP CI 2. ?7,0 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: DATE: 1°646 /19 t 7 PROPERTY / BUSINESS OWNER El OPERATOR / MANAGER El OTHER AUTHORIZED AGENT Er If APPLICANT is 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: COMMENTS: ACCEPTED BY: EMPLOYEE #: DATE: ASSIGNED TO: EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: PIE: Fee Amount: Amount Paid Payment Date Payment Type Invoice # Check # Received By: SR FORM (Golden Rod) END 48-02-025 07/17/08