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CFRVI('F RFC311FRT a EH0061SR revised 07/10/98 Type of Business or Property FACILITY ID # SERVICE REQUEST # O OWNER I OPERATOR i`' --f V- V s �c s )- BILLING PARTY❑ FACILITY NAME Su � c _,7 ! ct �� e- -K- Act SITE ADDRESS M0 A), LA � �"S ` /% P\ Q I,"\ e Q y— I Street Number Oxectlnn Street Name Type Suite I Mailing Address (if Different from Site Address) CITY STATE /t ZIP q S•- 3.3• PHONE #1 EXT. APN # LAND USE APPLICATION # CT^ PHONE #2 EXT. BOS DISTRICT; LOCATION CODE CONTRACTOR ! SERVICE REQUESTOR REQUESTOR ` /� /? %�� / -,C BILLING PARTY1 I BUSINESS NAME _yam PHONE # Exf. MAILING ADDRESS V FAX # 3 WI q wavtt ,b r CITY jc � G � O '� STATE C � ZIP �s BILLING ACKNOWLEDGEMENT: i, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, ST and EDERAG laws. APPLICANT SIGNATURE: ®ATE' PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANA R ❑ OTHER AUTHORIZED AGENT L- e I P C If APPLICANT is no the QItlING PARTY proof of authorization to sign Is required 4� Title AUTHORIZATION T ELEASE 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 PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICE REQUESTED: COMMENTS ❑ SPECIAL Cpm--"' • 1149 JACK M' Ji. COFFECOFFELTL 3113 CA DAr� 1" ®V BEVEFtL t ROAD 95207 1 $ 708 W' STOCCjCfON, D DOLLAR Q O PAY 70 TBE50 onaEl; of I__ / N �nA�yw WESTERN ADVANTAGE ` / _ IP®NAND �) Nv 8Avvenue r 7337 PalCAA95207 StocKton, �!- IJ�EtdO �� ✓✓✓ -- SERVICE CODE' ( ✓ U Amount Paid P-70,7,. oo Payment Date Payment Type s/ Invoice # 1 1,4.q Check # IYMENT- 1.61998 )IN COUNTY TH SERVICES LFT7Il LATE: DATE:2 (6zc DATE: �— PIE: lam(t(o(70 Received By: L Y5 .