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If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, L 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 ass4nent information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it rtyAgg jo me or <br />my representative. 71/ da0 <br />SAN JOAQUA COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1 47tha/ia cne— <br />FACILITY ID # <br />1\) -eiti3 <br />SERVICE REQUEST # <br />g 067 ?5 9 <br />OWNER / OPERATOR <br />P-24 f _ritc.- OM se-i": f CHECK if BILLING ADDRESS 0 <br />t FACILITY NAME 12\ 4a: i <br />SITE ADDRES dSi friak t <br />- Street Number Direction 4 <br />cA .frlairL In <br />)6 Street Name <br />Spl-e-v(ngti <br />City Zip Codo <br />HOME Or MAILING ADDRESS_ Ilf Different from Site Address) <br />r) EIO 4-tl- titanAten_ Cj---1 Street Number Street Name <br />CITY <br />54-0-4=44—,--04 <br />c AIATE ZIP <br />PHONE #1 <br />(2$ qa5.--11-n- ''.1 <br />Ext. <br />3-3 <br />APN# LAND USE APPLICATION # <br />PHONE #2 #2 EXT. <br />( / <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR n <br />/JOS r/A7Wil-) <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME n <br />tc2-11/ Pitc_ <br />PHONE # <br />(709) 9 <br />FAX # <br />t ) <br />EXT. <br />r1-7T?3- <br />HOME Or MAILING ADDRESS <br />/ 7 41 I) (--42- /Li-a-111,14d— Ct-r <br />CITY <br /> STATE as4 Zip c2 3Th....e? <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 />APPLICANTS SIGNATURE: /S-----2' DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />‘144111 •Dt-IneiC TYPE OF SERVICE REQUESTED: 11 All% VOP E etc.( VQ121 la -E. 1,5peth 0 n <br />COMMENTS: 9102 , 8 <br />6 ‘C13,9 <br />c.N.) € L,C) (OA- <br />IN a3akl <br />aliti tid <br />ACCEPTED BY: ro EMPLOYEE #: DATE: 9 _3 IL <br />ASSIGNED TO: \:--- (& Inr5chu 4- 2 EMPLOYEE #: DATE: C3/ &a <br />Date Service Completed (if already completed): SERVICE CODE: 042 i P/E: )45,0 "7) <br />Fee Amount: j . — Amount PS 73? 0 -D Payment Date 215A/0 <br />Payment Type Invoice # / Check # I/o g rieceied l3y:717,2 <br />SR FORM (Golden Rod) END 48-02-025 <br />07/17/08