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VokiN -2z-2_431KNA-1 \ - co or\ . <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />‘'''Z 001°1 `-{ U0 <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME U1/4 ....v-- <br />..k kA <br />SITE ADDRESS -Ili 1, <br />Street Number Direction <br />ChniOkee k--n <br />Street Name <br />\--Cal <br />City <br />Ci52,4b <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />c-)11 t <br /> <br />Street Number ‘2.4""*A\ Ctiteet <br />CITY CRATE Z <br />k OCAVVA IP41 2-UCH <br />PHONE #1 EXT. <br />C7A .1k 52- 1020 <br />APN # LAND USE APPLICATION # <br />PHONE #2 Ext. <br />(1A "bb427 5 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR , CHECK if BILLING ADDRESS <br />BUSINESS NAME ‘ --770,,, x • % " <br />A N `CNNIA C <br />PHONE ii <br />OA '2551 -1215 . <br />EXT. <br />HOME or MAILING ADDRESS c\ \ Lb czo <br />\t‘ Ckki 0(-\\ <br />•C')f-• <br />FAX # <br />( ) <br />CITY 'N\ t <br />(sKrE a= c;,e1.0 , <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 work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE nd FEDE AL laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNEReEr PERATOR / MANAGER El OTHER AUTHORIZED AGENT 0 <br />If APPLICANT iS not the BILLING PARTY, proof of authorization to sign is required <br />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 i rmation <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provideq <br />my representative. <br />0 <br />18 <br />7. <br />DATE: .61 1 1 1 YD <br />_ i <br />TYPE OF SERVICE REQUESTED.. <br /> <br />11111K4 plow ciAeck. - -1-71( 0 --r-v.,i,t.c.k_ Jo , <br />COMMENTS: " ? 4 <br />'44' Jo i., 4-4(virlQuiN <br />ACCEPTED BY: \I . al oam D EMPLOYEE #: DATE: -1--1 1 --I <br />ASSIGNED TO: V. 'Peale/A 0..3 /A EMPLOYEE #: DATE: -1.---1 i _I >7 <br />Date Service Completed (if already completed): SERVICE CODE: PIE: 1(4,0t <br />Fee Amount: elk,i, . bo Amount Paid Payment Date <br />Payment Type /7:(,4_, Invoice # Check # Received By: iffi <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08