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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Bu mess or Property <br />rood +(cder <br />FACILITY ID # SERVICE REQUEST <br />l't) 00-1 114 <br /># <br />OWNER / OPERATORMAck Jj_, <br />CPI \ oor CHECK if BILLING ADDRESS <br />FACILITY NAME T 1 0 0 YlaYi-r?-1 i <br />SITE ADDRESS ZYW <br />Street Number Direction <br />_5- A-i E Poet- um Y <br />Street Name <br />Si-oc-- /ii-/t <br />City <br />9's-zo 6 <br />Do Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />67 / 3 <br />Street Number C re S e0da Ave Street Name <br />C iTY STATE (J <br />SI-OC kb\ <br />ZIP ciczo LA <br />#1 EXT. <br />( 40/ 20 (I— is 63 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( VOS) 6,35-6533 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />.AiA`d-oL A5(Ailar CHECK if BILLING ADDRESS <br />BUSINESS NAME --t— <br />/ 0 ifla n 1--Z-PIA <br />PlipNE # <br />( 76o) 209= <br />EXT. <br />HOME or MAILING ADDRESS 6-//3 L ,-, <br />L ireseAl Ave <br />FAX # <br />( ) <br />CITY j STATE LA Zip <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 Or <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 rk to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL I <br />APPLICANT'S SIGNATURE: DATE: 7-//- zoi <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MA GER 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 locatedlitlfw,4e i <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess w, 6 <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prtie <br />my representative. <br />Jti..) y <br />TYPE OF SERVICE REQUESTED: SAN 1 201) j <br />COMMENTS: <br />pi (A, Yi ow atm) '00007 11477.v!,R0A,44/, ouNr <br />ri CI PA4...7"AL <br />/ITNr <br />EMPLOYEE #: DATE: q 1 1 1 1 ri ACCEPTED BY: WiMain 0e2 <br />ASSIGNED TO: U 1 11 --art S EMPLOYEE #: DATE: 0 0 i 1 7 <br />Date Service Completed (if already completed): SERVICE CODE: OZS P/E: &e-ji <br />Fee Amount: 4`5,1 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08