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DATE: y/1(11 ,62, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dr_rARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />A-CM ,V— <br />FACILITY ID # <br />F/3 <br />SERVICE REQUEST # <br />5I tO 7 97. <br />OWNER / OPERATOR <br />CjK) S T- q 9re4 git CI-C. CHECK if BILLING ADDRESS1D <br />FACILITY NAME I <br />I A CoMktfk-440 COtIt4g,SSoltit <br />SITE ADDRESS <br />2-1 CC) Street Number <br />,....— <br />I.- <br />Direction <br />1,0/ tta rei 4'1' ' Stret Name <br />540C t1,a- 04 <br />City <br />gCL d 5- <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from <br />- <br />Site Address? (i0(1 r <br />Street Number <br />Coror74 /0 AVC <br />Street Name 4° 4 S Cx_e ‘9-er,..4-0 ArAR,t <br />Girt STATE ZIP <br />_StbC faln_ C14 qYZ°4 <br />PHONE #1 EXT. <br />(P1) (47(.4 - it/60, <br />APN # <br />ikt).C104(j) <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />'-4-7-- . IR- , ett- ICY.— E I e` cr.- CHECK if BILLING ADDRESSEI <br />BUSINESS NAME <br />01')S \)r-- )2a/14. (IC <br />PHONE # EXT. <br />(2oct) Lib] 1.3 -, 4v <br />HOME or MAILING ADDRESS FAX # <br />Cyr), STATE c24 ZIP q,4 x_A(--1--oiA <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project Of <br />activity will be billed to me or my business as identified on this form. <br />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 <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER gi S PERATOR / MANAGEF-2-0-- OTHER AUTHORIZED AGENT 0 <br />If APPLICANT IS not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prcAtird to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: 4:2=X:1 v dild e-- 1 /15 pcd-zo4 --t+'46-Zr'kiii <br />COMMENTS: <br />Li C. i 9 Y-1 e I <br />4,4 Nilti, <br />42111f <br />0/p <br />V0 1/ <br />V <br />7- kc. 41, 445) 6,4„ 4,4 co <br />kit'? <br />ACCEPTED BY: 7 . <br />( CA <br />EMPLOYEE #: DATE: 4 .11,,I y <br />ASSIGNED TO: tildo..(-1 1,...1 EMPLOYEE #: DATE: 4 _1 i _ /s? <br />Date Service Completed (if already completed): SERVICE CODE: °le i PIE:11(63 <br />Fee Amount: t • Amount Paid /3:2 no Payment Date <br />Payment Type Invoice # Check # L5-S-6 Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)