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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DmPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />WNER / OPERATOR <br />(1 tiq criv -e- Va I a 01,- CHECK if BILLING ADDRESS <br />FACILITY NAME ( Vca.a (L2 z--- <br />SITE ADDRESS <br />1731 Street Number <br />DC( )---c_ s -I-. <br />Street Name <br />5 -oclic --ro IP1 <br />Cltv <br />9'S .2/ 5- <br />Zip Code Dlr ion <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(09 , y 0,6-4,3 <br />APN # ..---.' <br />j6) <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT i <br />e <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />d --e iii 1,7 ei U of a cl -e? CHECK if BILLING ADDRESS <br />BUSINESS NAME V , / / <br />Ci Ci d ? Z- crodi(- PH.QIINE # . <br />i.;20; <br />EXT. <br />D6 6 3 <br />HOME or MAILING ADDRESS <br />17i Dci.-1-r $ -f. <br />FAX # <br />( ) <br />crryi5.4„, ,, , is -1-0 11 <br />STATE <br />ZIP gii<-.— <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 />APPLICANT'S SIGNATURE: Iv //) _ATE: a--// 1 /47 / 9 <br /> <br />PROPERTY! BUSINESS OWNER Els, OPERATOR! MANAGER 0 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 or <br />my representative. <br />TYPE OF SERVICE REQUESTED: F \J1211(ci e- 1 ospe c-h0/1 Ike t.il COMMENTS: <br />Licenc_ p4-e- --4- 7O6c-6 ---7 t___ 1 <br />elfrE <br />Dc ,8 2O <br />a <br />0 <br />1 201; <br />811-Al JOA n , , cli/11 w Wilt HEAL rii&O/vwCOUN 7, <br />DEP,441724L <br />Itkk 7. DATE• 12_ /&• /-7 ACCEPTED BY:Ect i_tiI tth Q EM PLOYEE #: <br />ASSIGNED TO: r---"I EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: 0‘, i P/E: 40 <br />Fee Amount: 1 cl) 30) 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)