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APPLICANT'S SIGNATURE: Z. <br />PROPERTY! BUSINESS OWNER. 1 OPERATOR! MANAGER 0 <br />Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY R # 1 L rfi 06 i s---7 7 ci <br />SERVICE REQUEST # <br />OWNER / OPERATOR A _ <br />1 coifo,Z <br />CHECK if BILLING ADDRESS <br />FACILITY NAME •43 I - <br />-;)-. 4j4j: Li 9171 <br />I <br />Street Number Number <br />SITE ADDRESS 7;'... / <br />Street Name <br />e .c2/2 <br />City <br />'7 J) <br />Zip Code Direction <br />HOME Of MAILING ASIDRESS (If Different from Site Address) <br />— . Street Number <br />4--i ie 61(2 /ei A v -e-- Street Name <br />CITY, STATE ZIP <br />C61 ( 1 <br />PHONE1,1 EXT. <br />( Cif (o-I3 7k. 2 <br />APN # <br />0 II ii (1° / I <br />LAND USE APPLICATION # <br />PHONE #2 EXT. BOS 01ST Ft" LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR4 <br />1) <br />e , <br />1 <br />i <br /> 4)7 3 ' 7Wl,'Z <br />CHECK if BILLING ADDRES.. jc <br />BUSINESS NCIVil Wart/1i _t_.& ip 14- 4 Li] ) Li 9(.1 PHONE,/ EXT. <br />(z=i ilo- 4-7f., <br />HOME or MAILING ADDRES <br />V,20 C/9 40/11- 42i2 ;41-W <br />FAX # <br />( ) <br />CITY4:712, (..., STATE 07' <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 />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 a FEDERAL laws. <br />DATE: <br />OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 provided to me or <br />my representative. <br />liZe"?..IIWA TYPE OF SERVICE REQUESTED: -C,3C1 \,/ Q h le-) j 0 --p•-e2.410,r) clvz <br />COMMENTS: <br />JON 0 <br />1 <br />0- hCing k- C ."C ')1) SAN JOA <br />1 201e <br />HpfAlviRiguiN con <br />riDsp,iii,71-At <br />WAIT <br />ACCEPTED BY: 1Z....0.4 ret EMPLOYEE #: DATE: ?t, _ )—/ X <br />AssiGNED TO: Fah cyiq EMPLOYEE #: DATE: 6 / / y' <br />Date Service Completed (if already completed): SERVICE CODE: 0 Ii I P/E: <br />Fee Amount: 1 0----D -2_ ,— Amount Paid Payment Date <br />Payment Type Invoice # Check # Rec wed By,:y/7 <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)