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Title SAN JOAQUA COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property ___ j/- ea fal(.14 a FACILITY ID # SERVICE REQUEST # Er- 00 -71050 OWNER! OPERATOR CHECK if BILLING ADDRESS FACILITY Nr Nu - L-- 4 F R); - SITE ADDRESS 7 3 C' Street Number Direction S C-C' 1 1 t (SC:t)re'et iN -airne(4 i GIN Zip Code HOME Or MAILING ADDRESS (If Different from Site Address) 3 4' i( i'l 1/1) )/ /) \I I: Street Number Street Name Crry , STATE Zlp 0 (' 'an PHONE #1 EXT. Loi) C 8 -5-g CC APN # LAND USE APPLICATION # PHONE #2 EXT. ( i 7 ) '77 ga 9 BOS DISTRICT LOCATION CODE CONTRACTOR / SERVICE REQUESTOR REQUEST 9R / , ( CI FC( b/2 a' (--L/Z_ SW ii CHECK if BILLING ADDRESS BUSINESS NAME -- /:-'2,- A APq fr)Z --e_- PHONE # ( ) )-, --5•Ey -,.5 EXT. HomE or MAILING ADDRESS - , -1 / / il'//4k) /-) \/ 6- FAX # ( ) Crrv i cNI -) C ie-- ' (M i STATE 4P' 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 laws. APPLICANT'S SIGNATURE: ,Cido,/, 71' PROPERTY! BUSINESS OWNER 0 OPERATOR I MANAGER 0 OTHER AUTHORIZED AGENT 0 If APPLICANT IS not the BILLING PARTY, proof of authorization to sign is required 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 representative. TYPE OF SERVICE REQUESTED: FOO d VA (d,& T41,1 poi° r\ RE- twtN7- COMMENTS: Ctivz. Da 6 2 "•=0 si4A, Jo _ 2016 .. ovv AQuIA, c ryEkrti riomEAr _ouNi _v ocp4 p,,,tilt ACCEPTED BY: eg.../ A/Lemq iy.tit,i 0 4-11 EMPLOYEE #: DATE: ASSIGNED TO: tkil Ci 1149-e/1 Floh 11c • tz EMPLOYEE #: DATE: Date Service Completed (if already completed): SERVICE CODE: LC COU I P/E: /(pg Fee Amount: 4'. I C-/ Amount Paid -> / ..- q 7)0 Payment Date 2-12 /// _, Payment Type Invoice # Check # Received By: z ' DATE: EHD 48-02-025 SR FORM (Golden Rod) 07/17/08