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Alb/ END 48-02-025 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH bEPARTMENT <br />SERVICE REQUEST <br />Type of Business or roperty <br />))&A.e \\I-V2X- <br />FACILITY ID # <br />e.),A) <br />SERVICE REQUEST # <br />5R.06) 7 9a‘o <br />OwN,,R / OPERATOR"-, <br />\.& \--V\ c),)-VA v.‘C yCfC)\.N\ c63 \"*.\ <br />CHECK if BIL LING ADDRESS <br />FACILITY NAMEC-7. <br />SITE ADDRESS -k <br />1,...• -ikanot\a,cAW Vz,. (Ac.--,1/2-r- <br />City <br />. Clzc5 <br />Zip Code .. , ,,,f Direction <br />7 <br />HOME or MAILING ADDRESS (If Different from Site Address) k ckl._ .1 Street Number C565\10L \ C" Co' k.,k ge\eit) a me <br />CITY i 1/45:v STNE ZIP <br />-A <br />PHONE #1 EXT. <br />(AA) LCC;Cl --'2,c). 1 <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. BOS DISTRICT LOcATioACoDE <br />q7 <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR e <br />_.)&01....\ ca,c-,Ve% dri-\ CHECK if BILLING ADDRESS 0." <br />BUSINESS NAME <br />Sr\CM.V\-,\ C.---VY\ C/N.••••A <br />PHONE # <br />(j) <br />EXT . <br />HOME or MAILING ADDRESS <br />‘C\ 2A -.DCoe*e V,AA.C"\\"-\ •(' • <br />FAX # <br />( ) <br />Grt i <br />.....ZAA <br />STATE GA 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 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: DATE: <br />7 <br />PROPERTY / BUSINESS OWNER Bi- OPERATOR! FIi.NA ER 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 assessme t information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pro p.rne or <br />my representative. <br />TYPE OF SERVICE REQUESTED: j"---00Ci Picit7 c_he (-_,L. "c"%i-34111 <br />Si COMMENTS: 4Pi? 2 <br />41^1 Jo 5 n 201,9 -s• <br />itgivillquikeo <br />"1/0.4fkfr 447. <br />ACCEPTED BY: 1;?...6 (---ci EMPLOYEE #: DATE: ii• c‘25_ j? <br />ASSIGNED TO: ..(24 in 2-0 EMPLOYEE #: DATE: i-c9„. -5-.. ) y <br />Date Service Completed (if already completed): SERVICE CODE: 5.„2 PIE: i tf o i <br />Fee Amount: 4 n , te a—) Amount Pai 445—(,,, O, 0 Payment Date 44 i 5 <br />Payment Type Invoice # Check # 3 13 Recei ed By:7161 <br />Title <br />07/17/08 0C-Z43. SR FORM (Golden Rod) <br />/ r C/I" tjvkyO a c/0