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SAN JOAQUip, COUNTY ENVIRONMENTAL HEALTH 1.,tPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST, <br />5RU) ---) L-1 -1 <br />OWNER / OPERATOR , . <br />CtlY)1 '-\ i S5 4t c. 0 CHECK if BILLING ADDRESS EJ <br />FACILITY NAME <br />CA C Ka (a rie( t_-_- X / I -C\ I <br />SITE ADDRESS 2 coC) <br />Street NumberNumber Direction <br />&- lektrot6f) w 0,., <br />Street Name City Zip Code <br />HOME OF MAILING ADDRESS (If Different from Site Address) <br />2:S LA 5 ..g Street Number <br />g-7 g/()ra_ <br />Street Name <br />CITY x, STATE ZIP <br />C I< <br />9 s2os•-• <br />PHONE #1 EXT. APN # <br />9 I --3 -D_-) <br />LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ....--' <br />',Gli \A (1 () S S CWSKC7-; CHECK if BILLING ADDRESS <br />BUSINESS NAME 6' -,v1 ro virg-I .y1 <br />PHONE # (C\) fl )Akek 7 <br />EXT. <br />HOME or MAILING ADDRESS <br />.17-- L brCk SI-, <br />FAX # <br />( ) <br />CITY S.-ec c K---e_ 0 v \ STATE coA Zip CA c26 _c--- <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 at the work to b performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FED RAL laws. <br />APPLICANT'S SIGNATURE: <br />DATE: c5 <br />Title <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 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 />TYPE OF SERVICE REQUESTED: F(^_ock \) Oil id c \ iL,10.ec4--)or) ieu 1 fig Eli <br />COMMENTS: L 414 y 0 1 c_ # li Up 0 CO -7 4 0 <br />s'IN Jo A., Eiv fri4Quhv <br />"'Eiltrz, 6'044ES( <br />, Ot-p iv ri Afiriti <br />ACCEPTED BY: ..........ec--•\ ( 0 EMPLOYEE #: DATE: 5 zo <br />ASSIGNED TO: LAO V\(.4 C e"---- EMPLOYEE #: DATE: 5 2%3 i< <br />Date Service Completed (if already completed): SERVICE CODE: bc p 1 P / E: ) (ca <br />Fee Amount: \-70000 Amount Paid ;4) /3(", ,..)-D Payment Date 24 /,_) - <br />Payment Type /---1r.„---4k Invoice # Check # Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod) <br />51' /1149 0