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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />so. co-uis i <br />OWNER! OPERATOR <br />CHECK If DILLING ADDRESS 1111 <br />FA atm NAME <br />‘..-Q—C I \ \ 1 04'4.9. 1 ,,I gct cotx <br />SITE ADDRESS <br />LiqC5? Street Number Direction LI treet Name `5N-4>C141-,0 <br />Cite Zlo code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />___,20e) OC t.0 (s_. 1-1.) Street Number Street Name <br />CITY STATE ZIP <br />I---CteJU C-A c1V2-t( 0 <br />PHONE #1 LAND <br />( .2ez, ) 5 4o 3 be? 6 <br />USE APPUCATION # AP6I if g ..7... t 2, 2 0 5 <br />PHONE #2 • BOG DISTRICT <br />( ) <br />LOCATION CODE <br />5f-GC/ktrYi <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR -- <br />c__ <br />\-- <br />N.-4)(c cer.t... 7.-- <br />CHECK If BILLING ADDRESO <br />BUSINESS NE 3 c veo .9e. exy 0 co, ,c, 5 PHONE # <br />( ,2::,5) 3-9-0 3 L, 9 c) <br />Err, <br />HOME or MAILING ADDRESS <br />Orto LL 1...yx 1,-,4t, <br />FAx# <br />Cll.), c <br />9.10c1 <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 <br />or 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 />PROPERTY BUSINESS OWNER 0 OPERATOR / <br />'\,, <br />CAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not I e BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />alme site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TvE ople060A I i C":_olia Aw, 66---4151•• ic) la CeWic- r''C At' dic II r rtEN <br />kozi 2 s Tat <br />couktri ,,, 30 p3T4034110-1- <br />SPk eistV‘P•4,. -Irn i , <br />AccEpAlticr /- ...r EMPLOYEE #: DATE: <br />r <br />As SIGNED TO: .5' tt 1 EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: Op....1_ P 1 E:D 4, i <br />Fee Amount: Amount Paid q ,5--, _ Payment Date crn i a <br />Payment Type Invoice # Check # Received By: ti3 <br />APPLICANT'S SIGNATURE: cf DATE: -,101-go <br />Title <br />EHD 48-02-025 <br />REVISED 11117/2003 <br />SR FORM (Golden Rod)