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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ii-Ar) t 1 i. FCC o Fel elllc_it , tl,k,a_k FACILITY ID # 2,2-,2 -.5' -1 SERVICE REQUEST # !..DC.) -73"12-5 - 1\ 66 OWNER / OPERATOR CHECK if /A (c c,E1, tf-1 A) (1- I_ t i 1.1‘.) '--k BILLING ADDRESS FACILITY Ni ,fIE tikt)-ST IA. triNA—LkAil, Street Number Direction SITE ADDRESS 'Zgee) 1 t'eet r 'ame City Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) /1-' 4/ 5- 5 `..;r1e.-2--_,,,A, ct7,c. c I \ .• •::::: ( Street Number (' A Street Name CITY STATE ZIP PHONE #1 EXT. Vey ge)( ci 6 ( c APN # LAND USE APPLICATION # PHONE #2 Exr. 2_ (--)4 -74r BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUESTOR \\A 1 C\VIII If\ 111d 1.-uvq,t CHECK if BILLING ADDRESS BUSINESS NAME (--J s--.0 CisAr \ I-Ck i\l a ri ck. PHONE # (2.1A) 1 I I - 9t 5 t 5 F XT HOME or MAILING ADDRESS 1 0 4 5 5 . 5 3 - .‘‘ G•- 16 il. 5•- Le FAX # ( ) Crry 5.6 cw_c) n STATE C p,s. ZIP 952_0 6 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 Of activity will be billed to me or my business s identified on this form. I also certify that I have prepared this application an that the work to be performed wil! oe don_ in accordance with all SAN JOAQUIN COUNTY Drcirlance Codes, Standards, STATE a FEC::RAL laws. APPLICANT'S SIGNATURE: DATE: PROPERTY / BUSINESS OWNER re OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title AUTHCRIZATION 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 OF my representative. TYPE OF SERVICE REQUEST ED: i-r1(9 VeAl (A -C Jr) ..reCjf-161 PPE-4}eili COMMENTS: - C... oe-c, silly do 2 3 ii €111,4% t;Itt 410 I A' c it 04A-,v , . ),,i, ACCEPTED BY: EMPLOYEE #: DATE: (Z/3((2,1 C.;-- '" ASSIGNED TO: V6eri EMPLOYEE #: DATE: 1 4.2;f1C Date Service Completed (if alieady completed)': SERVICE CODE: 3c_7Ca ( PIE: Fee Amount: 4( 0 -- (50 Amount Paid Payment Date Payment Type Invoice # Check # Received By: EH D 48-02-025 SR FORM (Golden Rod) 07/17/08