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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Fr c- 6 A ' <br />FACILITY ID # SERVICE REQUEST # <br />caie_c_67-Li lc / <br />OWNER / OP TOR _....--7 d CHECK if BILLING ADDRESS <br />(4) <br />FAciLiTY NAME 00;1 <br />0 0 0,1, ct <br />i ITI rESS I <br />Street Number Direction Lt9 0 H ,...., liaLtioct PvC / l'r lt,` c-1 Zip Code <br />HOOf.,MAILING AqDRESS (If DiffeTnt <br />1 D k <br />from Site AdlTs) <br />i c\Act...1"Jul , Street Number c--n , Street Name / -5 3 7 C:2 <br />CITY,1-, STATE ZIP r <br />PHONE #1 O EXT. <br />616) _S Li — 0 /d...... APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR R <br />k 0 0 c), \(-.1. c)\/ V\ S<__(-) V\-/ CHECK if BILLING ADDRESS EJ <br />BUSINESS NAIVIE go sc\ cil, el_ 1- CA\ 0 5 o t'--.) Pgib#) 0 4'10 3 lx-. <br />HOME or MAILING ADDRESS 3 cc 0 j 1 il . <br />Cu ir 1 \ ,va 0 v c- <br />FAX # <br />, ) , r--- ow STATE 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 F E AL la S. <br />( PROPERTY / BUSINESS OWNER OPERATOR! MANAGER <br />If APPLICANT IS not the BILLING PARTY proof of authorization to sign is required <br />APPLICANT'S SIGNATIJRE: DATE: 0 t" 1 <br />OTHER AUTHORIZED AGENT 0 <br />Title <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 assessment information <br />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 <br />my representative. <br />TYPE OF SERVICE REQUESTED: IA. \,) I , Or' <br /> <br />REcEtve1 " <br />COMMENTS: OCT 2 2 bi-----e)-‘4--C7L—' 201 <br />SAN do <br />etivin .v cou HEALTH apmENTAL <br />v' N 4 c.-0,3 C_-) 2. 3 GO Q G I 4161 CA 2 an ninEi <br />ACCEPTED BY: C rci EMPLOYEE #: DATE: lc) ) j( <br />ASSIGNED TO: \Awl in v-) EMPLOYEE #: DATE: <br />Date Service Service CompletLI (if already completed): SERVICE CODE: Q(4' 1 P/E: <br />Fee Amount: \ ey() Amount Pai /36 .60 Payment Date - , /(--- <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)