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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />AG (In <br />FACILITY ID # SERVICE REQUEST # <br />OWNER) OPERATOR riA if BILLING ADDRESS A AD DRESS Cr,Ckf h if IX) 7 <br />FACILITY FACILITY NAME pcky\ 0) \ cN. fit <br />)11V\D V \- (e ' / 01\C-1C 1 <br />SITE ADDRESS q its <br />Street Number Direction <br />S (2ck_ 1 I 0 (,,,,Q En e <br />Street Name <br />- <br />LOCl/ <br />City <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />CI(J:Qiti, 7 Zip Cottle( <br />A ME <br />Street Name RECEIV CiTY STATE ZIP <br />1)E.0 <br />sAN <br />PHONE #1 r`, ,.., , <br />(5-) L r)-1 <br />Err. <br />.--7(0)-1-1 <br />APN # LAND USE APPLICATION # 1 3 20 <br />PHONE #2 F, t ,"\ ,..._ _ ., E. BOS DISTRICT LtigatellaNi EN TAA <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Andre LAD G ekr----zp CHECK if BILLING ADDRESS M <br />BUSINESS NAME D 1 i ancui_ r, <br />__N\-\okf <br />( \I 1 <br />(.N\ACK <br />PHONE # <br />( SV ) C19--) -7(0)-(4 <br />Err. <br />HOME Or MAIUNG ADDRESS , —( <br />1-19 wodlow LI), <br />FAX # <br />( ) WA <br />CiTY Lc ot i' STATE CA ZIP 9S-1.9_9 6 <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 <br />or 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 0,nd FEDERAle-, jaws. <br />APPLICANT'S SIGNATURE: <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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUN FY ENVIRONMEN IAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />rovided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Ora \ on )-€Vi_tj <br />, COMMENTS: 1\ <br />P7Pp\ \ilh -48( (7 Co -kei‘\(\cl k • reiNt-) 1L-enSe___, <br />ACCEPTED BY: S , eb @qv) ali n EMPLOYEE #: DATE: I a _ 1 3 ... a 3 <br />ASSIGNED TO: F . -RJu i z EMPLOYEE #: DATE: 1 _ 13 .... a 3 <br />Date Service Completed (if already completed): SERVICE CODE: Pt PIE: (oci____ <br />Fee Amount: (4.2-- Amount Paid/,,2 .00 Payment Date <br />Payment Type ri-- Invoice # Check # 173 3) 241 By: Received z.B <br />DATE: w.g4,•••••••me.w....., <br />- „ <br />PROPERTY / BUSINESS OWNER qa OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />kz-/-7-- 03 <br />3 <br />Ty <br />IT <br />091 VTO SR FORM (Golden Rod) END 48-02-025 <br />REVISED 11/17/2003