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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST <br />cl007 <br /># <br />1 q 3 <br />owBER, OPERATOR ( <br />CHECK if BILLING ADDRESS JO ab 3t- L0\31 vA vl WO' . <br />FACILITY NAME ( (st /R, d o\ ct6 C o 0,,t. 1044 c <br />SITE ADDRESS <br />1 'A \--k. Street Number Direction ,_‘.tr\ ; an 3)r Street Name (*)6VA\ QA cC5-, cW5 <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />---1.1 5 A- ()war 54- Street Number Street Name <br />CITY STATE ZIP <br />CkS1.0S <br />PHONE #1 EXT. <br />(PI) (a 't•- 9°1(4 . <br />APN # LAND USE APPLICATION # <br />PHONE #2 En'. <br />(%()q A( SA -6-Co <br />BOS DISTRICT LOCATION CODE <br />cfrixklv,,, <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />116,-(A-es <br />CHECK if BILLING ADDRESS <br />ty) 6 <br />BUSINESS NAME 014 PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE 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 appli on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST nd DERAaw5. <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT /S not the BILLING PARTY, proof of authorization to sign is required <br /> <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 IL is pr' '..-yto me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: <br />1 t.,.. C <br />-i'LetLfz,z7 i, <br />COMMENTS: <br />Nancit c 00errhi <br />NOV <br />-a ,Q e0/8 it, eie 4, <br />' 7 DE'R,W747.‘1471), <br />"If?7;,,A14 <br />4747. <br />ACCEPTED BY: (._ civra csotim{c EM PLOYEE #: DATE: /1/ <br />ASSIGNED TO: v ia t (tor 1 e t 0 hare j EMPLOYEE #: DATE: 11/ <br />Date Service Completed (if already completed): SERVICE CODE: 0(6? 1 P / E: IC, 0;2 <br />Fee Amount: 152_,V0 Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />DATE: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08