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SERVICE REQUEST # Type of Business or Property <br />f3061 re I x cc( <br />FACILITY ID # <br />PHONE #2 <br /> Ex <br />) F <br />IT:is DISTRICT <br />r <br />LOCATION CODE <br />OWNER I OPERATOR <br />C 5 CHECK -if BILLING ADL. ES: 0 <br />FACILITY NAME <br />C F.;-tesi e6V-iVe Cox,q <br />SITE ADDRESS srait, rettnel 13'40 E Street '.umber Direction street nirne <br />HOME or MARIN( ,If Different trosn Site Address) <br />999 earcadvo Street N <br />C.:Oa <br />Street Nan, <br />( <br />PHONE #1 <br /> EXT. APN # <br />110 <br />1- LAND USE APPLICATION # <br />STATE <br />?j 2 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />CONTRACTOR / SERVICE RE UESTO;:, <br />RECK E'', FOP 4/ ; <br />/If ti f fl e 0 S 1-- CHECK if BILLING ADDRESS 121 <br />BUSINESS NAME ,--) <br />L 6> 5 f a':.0 1`• - /LC s is 14 /e/71/e eo X ,--k.. PHONE # <br />(2D1) <br />EXT. <br />IC9 - 060F <br />LI 9 '7 <br /> <br />2e2rLL'7ct o <br />t <br />C t 4- <br />HiplE <br /> <br />or MAILING ADDRESS Fax # <br />( ) <br />CITY 4 cd , c STATE Zip f5 z 4,7_ <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 ork ji1e performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FED <br />PROPERTY / BUSINESS OWNER El OPERATOR/MANAGER El OTHER AUTHORIZED AGENT El <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 above <br />site address, hereby authorize the release of any and all results, geotechnical dat, 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: od --P \ cir-) r V) e cL <br />COMMENTS: PA lem <br />te „3 ) ruct- REC 4/7* <br />AUG 2 9 2016 sil l y, -afi Qu <br />ACCEPTED BY: .')-y1 la., i\Atkii (1(2— TOfk <br />EMPLOYEE #: 11c4AIrricout1404iN cr,iuy 7.yor <br />ASSIGNED TO: . ''t EMPLOYEE #: DATE: L r <br />1 t <br />Date Service Completed `(11 already completed): SERVICE CODE: -2-. P / r: 0 / <br />Fee Amount: r_4 ) —) — Amount Paid Payment Date .i 1 <br />Payment Type v A Invoice # Check # o4-534 (,, Received Byr ) <br />EHD 48-02-025 <br />07/17/08 SR FORM (Golden Rod) <br />.PPLICANT'S SIGNATURE: C-- DATE: