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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />L2- 00/ CI 2°1 \ <br />OWNER / OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME <br />—1-4 C 0 17 ( C-1 GLLO <br />SITE ADDRESS 2 ,...i,40,----, <br />Street Number Direction <br />i3\\ (2 194 ..1 A, v-x_ <br />Street Name '3 city zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) -ILA 2,--1_ <br />Street Number <br />-.,\,/ \ \/e4 vl l'/••/e_, Street Name <br />CITY <br />NV-) C\1/4-QC-V-C) <br />STATE CA Zip - <br />PHONE #1 EXT. <br />(2-21) Cu li IV 1 <br />APN # LAND USE APPLICATION # <br />PHONE if2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR % _ _ <br />PC-A .A. a \ 3 yt1 f 147 CHECK if BILLING ADDRESS <br />PHD <br /> <br />BUSINESS NAME <br />-1-7k_C'UlkA. C) 3 <br /> <br />(ZOINE I) al 1 N? -1 (.02 <br />EXT. <br />HOME or MAILING ADDRESS <br />20. z—t \v7', 1,---1 iNv e <br />FAX # <br />( ) <br />CITY (V "\. 0(*PCs \----->-- STATE ZIP el <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: Aff,,,d <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR! M AGER 0 OTHER AUTHORIZED AGENT 0 <br /> <br />/f 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 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 />TYPE OF SERVICE REQUESTED: V:::EDO <br /> COMMENTS: <br />_ <br />NOV 1 9 <br />8Aisi JOA 2°0 <br />4V/R QUM/ C i-/A, 0(hio, <br />ACCEPTED BY: N/. V\A., otef2AAAD EMPLOYEE #: DATE: <br />ASSIGNED TO: , . 9‘,V\ M/14. ‘')/ ' EMPLOYEE #: DATE: \\ ..--\C\—\ q <br />PIE: 1 Lo cTL Date Service Completed (if already completed): SERVICE CODE: <br />010 k <br />Fee Amount: 4 rg . GO Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)