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APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNER 0 <br /> <br />DATE: 5 <br />OPERATOR! MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />0/t <br />SAN JOAQUOICOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />l'36 79/ <br />OWNER 2)PERATOR cf7" /11 E_(5,// 1 / 0 7 ,.4 CHECK if BILLING ADDRESS <br />FACILITY NAME 7--.- -D .eA7,9/z-C) "1;1 5[1,,,. <br />SITE ADDRESS <br />/7/ / Street Number 4:ection CJ 41/'* 4/ ifX Street Name <br />k:_r(43‘--.4.,,b4/ <br />City <br />% <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) A /2 z-2_1 ..- 7:treet Number 1 Street Name <br />CITY,, Z STATE <br />PHONE #1 ExT. <br />' ° 9/2- (Z( <br />APN # <br />//096(101-, LAND USE APPLICATION # <br />PHONE 42 EXT. <br />( ) <br />BOS DISTRICT <br />50 1 <br />LOCATION CODE <br />01 <br />CONTRACTOR / SERVICE RE UESTOR <br />REQ ESTOR /4,„,51 <br />Zi7 "----- ' 06/L0 Al CHECK if BILLING ADDRESt <br />BUSIN S NAME PunN # EXT. <br />92 ? <br />HOME gif MAILL.B ADDRESS 2 / <br />.7- <br />FAX # <br />CITY r' c.70-,---7-fr 49 <br />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 FEDERAL laws. <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required <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 i rmation <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provid <br />my representative. ft.)31) <br /> <br />, to-Ey p <br />TYPE OF SERVICE REQUESTED: FA \) Vitel-e 1 il `7peci-10)1 J414y <br />COMMENTS: 1 / <br />4.11VJO 20, <br />41/44k# Lr c--0/6-e 4/ok-1?z41-4 4R7-4,44r. <br />ACCEPTED BY: (--..Q --k. <br />0 (CA <br />EMPLOYEE #: DATE: .0_ /y <br />ASSIGNED TO: Lio haiv2,4) EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: to I PIE: ILO ._-, <br />Fee Amount: 1,--'). - Amount Paidll) /Sr?, 0(-) Payment Date <br />Payment Type Invoice # Check # (!;---3I 7E-3--7g Received By: <br />END 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)