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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DtPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID !! <br />FA ODD \ SS S <br />SERVICE REQUEST # <br />' ----2_ <br />OWNER! OPERATOR <br />10 s-e Do le_t 0 C-\ ox I \/-\ n \/i I ct ei--?f- CHECK if BILLING ADDRESS <br />FACILITY NAME ----A-71 LO S ... t ç7. i\ L---°1 2-Iq- <br />SITE ADDRESS V-1 1 -1 <br />Street Number <br />C5 <br />Direction <br />vit vsx W -' c-,4 <br />Street Name <br />c-,\--ock—c---\. <br />City <br />9 c-z, OV <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />\ 1 q <br />Street Number <br />BC C 1, 124, VVII A-r>f NI i -e 4 \ Rc <br />Street Name <br />Crry -\---06 'V—AID\-\ STATE Gar <br />ZIP <br />,11.1051 3 ,i 13 #1 <br />VU 1) 1 <br />EXT. ..... <br />0 -11 g5 APN # LAND USE APPLICATION # <br />PHONE #2 <br />( ) <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ° S c 961 ai 0 1-1A 1 v---,1V\ Val CienQr- CHECK if BILLING ADDRESS ' <br /> <br />BUSINESS NAME --t-74 C 0 (...) q....„ I j2eiv * LILcii 21 ig P(HA#) 301 0 .._____ 1 q .X1$ <br />HOME or MAILING ADDRESS ca) <br />1 >X, 11 4 Lo FAX # <br />( ) <br />CITY <br />h)(AZ--h)\-k STATE OA ZIP 21 S7 ()-1 <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 Of <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: <br />PROPERTY! BUSINESS OWNER 0 PERATOR / MANAGER OTHER AUTHORIZED AGENT 0 <br /> <br />If APPLICANT is not the BILLING PARTY proof of a thorization to sign is required <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 asses <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it i <br />my representative. <br />TYPE OF SERVICE REQUESTED: 1-IDC1 vto, cif Vk'pe.,d'iNA- t• "---4`-cTilio rt <br />COMMENTS: <br />84 <br /> <br />494/Vj <br />0/ <br />2049 <br />/1 04..p4i441/10), <br />Alf(1-44./vl. 7. <br />ACCEPTED BY: \/. vv-1,0,112, v-I c EMPLOYEE #: DATE: <br />ASSIGNED TO: V C. 1 (i j4 Q1NS _ EMPLOYEE #: DATE: '2-1)-- ICI <br />Date Service Completed (if already completed): SERVICE CODE: 049 PIE: 14003 <br />Fee Amount: <br />t e57 Amount Paid /6 c,71 OD Payment Date <br />Payment Type Invoice # Check # Received By: 7,7 <br />DATE: t <br />ent information <br />d to me or <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)