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I also certify that I have prepared this <br />COUNTY Ordinance Codes, Stand <br />APPLICANT'S SIGNATURE: <br />ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />id FEDERAL laws. <br />DATE: <br />PROPERTY/BUSINESS OWNER OPERATOR / MANAGER 0 <br /> <br />OTHER AUTHORIZED AGENT El <br />SAN JOAQ, COUNTY ENVIRONMENTAL HEAL JEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1---ocii) 772 U-(.- <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR <br />-APi4") Se--12/\-\#) 14-E---A p CHECK if BILLING ADDRESS <br />FACILITY NAME . TA- 5 7—e•E —774A-i <br />SITE ADDRESS ADDRESS <br />t• q °C) Street Number <br />/44-26 eA/CD ki A-y <br />Street Name <br />s-roci. , 0,-.) <br />City Zip Code Direction <br />HOME or MAILING ArlaRESS (If Different from Site Address) <br />Street Number <br />L_. 4 j,'-t)6e-it 57— <br />Street Name <br />CITY /11-- A/ re-CA STATE 0.4 ZIP 50 3--3 -3 7 <br />PHONE #1 EXT. <br />( a061) 2 -7(0 - i --7 S <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />(91(0) 2 62(r61 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ----- <br />D iraipkAs) Ser-Ayl(r&k-\0 CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />--- \ ---AS <br />EXT. <br />P(2V11) 2,1L0 -81 2-S <br />HOME or MAILiNG ADDRESS algki, tAviwioa c--v <br />FAX # <br />( ) <br />CITY (WW1VeCiA- STATE CA ZIP q S-3+ <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 <br />or activity will be billed to me or my business as identified on this form. <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the pAr time it is <br />provided to me or my representative. //' <br />TYPE OF SERVICE REQUESTED: -50d \LP/int CIO play\ cAkok_ <br />commENTs: , 12p\oit,iiwci c...ul3 d oct, evkock._)4 oEc /5 2049 8/INJoA k-Aril QUA, <br />%IL ii'avitt COu4, <br />7/410 84111.,47:1z 7/' -.7-444.40. <br />ACCEPTED BY: \I . W\ONAQ-A/N. 0 EMPLOYEE #: DATE: t 2. \ i Lp \ koi <br />ASSIGNED TO: • ke.eiv\4.0 . ° <br />EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: WA 2 PIE: UoSir <br />Fee Amount: -it (og (4 — Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/200