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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />, <br />_SERVICE REQUEST # <br />Sg °O?W133 <br />OWNER/OPERATOR Denise Rivera CHECK if BILLING ADDRESS <br />FACILITY NAME Rivera Residence <br />SITE ADDRESS 2111 <br />Street Number Direction <br />Waudman Avenue <br />Street Name <br />Stockton <br />City <br />95209 <br />Zip Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Exr. <br />( ) <br />APN # <br />08029026 <br />LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />( ) <br />BOS DISTRICT R LOCATION CODE 9 9 <br />CONTRACTOR! SERVICE REQUESTOR <br />REQUESTOR Acorn Onsite, Inc. CHECK if BILLING ADDRESS <br />BUSINESS NAME Acorn Ons it e , Inc . PHOcklE, <br />( 2 447-5200 <br />EXT. <br />HOME or MAILING ADDRESS 2288 Buena Vista Avenue FAX # <br />( 925) 447-0919 <br />CITY Livermore STATE CA ZIP 94550 <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 F. pERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br /> JUN 2 ) 202i <br />PROPERTY! BUSINESS OWNER 0 OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 15 v13 <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 <br />above 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 />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />Engineer prepared OWTS Plan review. JUL 07 <br /> <br />A exiiva 202/ <br />(#14445/4 QU/ 4 reaS Coo.. <br /> <br />" ii,141-N7Y 476)V <br />ACCEPTED BY: ."'".9e-!...-7_,Z____ EMPLOYEE #: DATE: 7/7/81 <br />ASSIGNED TO: NA EMPLOYEE #: DATE: —7/7/2 1 <br />Date Service Completed (if already completed): SERVICE CODE: -4,;--z 3 PIE: 11)01 <br />Fee Amount: sit 309 Amount Paid 436107) Payment Date 7/-1/-) i <br />Payment Type e_K_ Invoice # Check # /537 Rece ed By: CR— <br />END 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003