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CHECK if BILLING ADDRESS <br />APPLICANT'S SIGNATURE:)( r DATE: <br />OTHER AUTHORIZED AGENT 0 PROPERTY / BUSINESS OWNER OPERATOR / MANAGER 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />_ <br />FACILITY ID # SERVICE REQUEST # <br />OWNER I OPERATOR <br />VI cl a•A n 0 OAOCA- CHECK if BILLING ADDRESS <br />FACILITY NAME ArocA /c.. 0 c v1.00,.2.0 ci g....k 1 F 1 <br />SITE ADDRESS -2_ 01 00 <br />Street Number <br />v-- <br />Direction <br />4- \11‘120k\nr t'• An <br />StreerName <br />GA-Y----1 <br />City <br />191CD-2 0C; <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) -2---1 S <br />Street Number <br />) . S---1-1,-\ (-2, k- . <br />Street Name <br />CITY 5:hr) <br /> Ck(---4-1-/-\ <br />STATE CA ZIP c-1 s_z_u40 <br />PHONE #1 EXT. <br />Coq <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <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 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 />--I <br />If APPLICANT (s n t 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 assessmAt information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is 1547.4),„,t,Lme or <br /> <br />'Tr '17 <br />TYPE OF SERVICE REQUESTED: c0 0\ V e V 1 ak VIC-yeGVI NOk <br />)j# <br />COMMENTS: COMMENTS: <br />9411/./0 29 2g, <br />It/4114Qiiiiir - /8 <br />' ' 'Cks,0414j- 414'4, <br />444;14 <br />ACCEPTED BY: yv‘ 0,7‘Q. v\ c) EMPLOYEE #: DATE: t \ ,.. <br />ASSIGNED TO: ce,Nk.e.EMPLOYEE . #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: c)c.. ‘ P/E: Ra6 S <br />Fee Amount: * 1 5 2 op Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />my re resentative. <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)