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(1t (C) <br />cl.EXT BUSINESS NAME S 3 S 44- C t(-71 9 .36z-U <br />REQUESTOR (r;-) CHECK if BILLING ADDRESS, <br /> <br />HOME or MAILING ADDRESS <br />c 4-C't <br />CITY <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 t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE d FEDE L laws. <br />APPLICANT'S SIGNATURE: <br /> DATE: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 <br /> <br />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 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 Of <br />my representative. <br />FAX # <br />) <br />SAN JOAQUio, t.:OUNTY ENVIRONMENTAL HEALTH ARTMENT <br />Abo. SERVICE REQUEST <br />Type of Business or Property <br />mo (3 t LE -Fool> 71--eLt-C.,-.. <br />FACILITY ID # SERVICE REQUEST # <br />OWNER / OPERATOR ----, Lk. 4e-i-k V t I-I, Per— 1..1-4.G)t-{ CHECK if BILLING ADDRESS <br />FACILITY NAME LA la. le si- C:5 1,-4 V\-)- Irt S-la-1.., S <br />4411:(5)Fteit t - &LA to1 /41:11---(1,,c,X,....-c <br />Street Number <br />k <br />Direction <br />73c, s . cc:x.4_4z, ' i it st-- S-A-2, cxe----A-rn 1,s- zi5-2 <br />Zip Code <br />rr.‘. <br />Street Name City <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />5 S 5 C.) k-t E-47--Irct A--t-4:_c„..c, af.te Street Number Street Name <br />STATE ZIP <br />-0=N.-- <br />-to Cm( s c_v_.-ton. <br />PHONE #1 ExT. APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( 5 1, 0 / ca‘ "' 6\ elk C% CI 6,-/-z- BOS DISTRICT nc 1 LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />TYPE OF SERVICE REQUESTED: ma -0 --1-t_si,t - —7 , --ki-ei• COMMENTS: J <br />Ficoct P y) Ci'Li-CIL- a <br />ii — A i <br />RECLIVED <br />i',11 i 6 2 201.8 <br />SAN JOAOUN COUNTY <br />ENVIR NMENTA <br />ACCEPTED BY: ict EMPLOYEE #: HEALTH c EPAPTflit, NV., <br />ASSIGNED TO:1.5" i c 1,1 1--. .-- )u_l_ z EMPLOYEE #: DATE: (5. . . V <br />Date Service Completed. (if already completed): SERVICE CODE: .-_ ---) -- PIE: 1 te c j <br />Fee Amount: Li, 56.1 Amount Paid .45 (.. Payment Date is'' /a j h <br />Payment Type Invoice # , Check # i 0 (9 & Received By: <br />END 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />10-