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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ‘C-Otrk00 I -D-LS h'it G FACILITY ID # rikot0/ 3 3 8( SERVICE REQUEST it SCZ00,3'.3--otLo OWNER I OPERATOR _ Lt ne/6 h k.) S nhe,d, i okooi CHEcx if .156-1-1.c,A BILLING ADDRESS 111 FACILITY NAME-Etc/1d 0 -v,,c-earylec Nor-i-k SITE ADDRESS 2_0 i u Street Number Direction pol t onqn (4\le, Street Name sbc,k_i-oy-A City 95209 Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) Street Number Pd Street Name &k CITY STATE ZIP PHONE #1 Exr. (209) 9 5-8(0G5 APN # LAND USE APPLICATION # A U6 s4 N PHONE #2 EXT. ( ) BOS DISTRICT LocATiopy - T H Di CONTRACTOR / SERVICE REQUESTOR REQUESTOR k 6 ,... (.0)( (t CHECK if BILLING ADDRESS El BUSINESS NAME •-, 1 O Nuhhart&evic L. • u. • S 1c7. (;t tS A PHONE # EXT. 0:9)95?) — - a1,9 HOME or MAILING ADORES S cp2 5 arristourj PV s int (29)e FAX # ) Lill --11-1cpS Cm,' si-ocktbn STATE C44 . ZIP 95(20-1 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL law APPLICANT'S SIGNATURE: 1Z. DATE: 0/i 12 PROPERTY / BUSINESS OWNERD OPERATOR/MANAGER 0 OTIIER AOTITORIZED AGENT,!;. CC:01"6 not r- ii-AppLicANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property Located at the above site address, hereby authorize the release of any and all results,. geotechnical data and/or environmental/site assessment information 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 my representative. .I .,.. TYPE OF SERVICE REQUESTED: clync---ap,i-xyz en -fry AiOned.,:snep azz,zi2(p./ COMMENTS: KILot. Co KUX. &11,1,S614 /1-a- DATE: SI/A9,3 DATE. DATE: ///t_3 AccEPTED BY: _ 1 --- EMPLOYEE #: c7.s7 8/. ASSIGNED TO: 1 C4S-00 , EMPLOYEE #: Date Date Service Completed (if already completed): SERVICE CODE: 069 i 1 E: b0 , . Fee Amount: II/ 09-- Amount Paid 9— Payment Date 8/0\13 Received By: ...., ,. Payment Type C4./e7Jj-- Invoice /I Check # /7,61.---72.2 5/ EHD 48-02-025 REVISED 11/17/2003 06-14)putlion /62&1 7,2),2-37" (Golden Rod) PRO92:12:15