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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />(10% DAVVDA 6 (A <br />FACILITY ID # SERVICE REQUEST # <br />3 RWS7c1CP0 <br />OWNER / OPERATOR <br />1-14C4111W1AA Mt \ikook CHECK if BILLING ADDRESS <br />FACILITY NAME 4 4 IA s .,--R2..ric. 3\ r 1--,,,.., <br />SITE ADDRESS <br />61-1 1- Street Number Direction <br />1-1 Mk)/ SIC <br />Street Name <br />S6CACA-0 (-) City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 6io Street Number NO-le A- ye So`ce-4-1-0c1 Street Name <br />CITY Vierityr\ 50 okh srt c \mac; <br />l.0 6 <br />STATE ZIP <br /> <br />PA qL1021:=. <br />PHONE #1 EXT. <br />(666 WI <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />Ash\e. , vil rvto CHECK if BILLING ADDRESS <br />BUSINESS NAME IA g c;tv k v.,4i peim ieuv„ T., , ) 1 (TN (1. <br />EXT. <br />HOME or MAILING ADDRESS <br />ILIC1 r B1-- <br />FAX # <br />( ) <br />CITY <br />Ciall' <br />ATE ZIP q1562 ,2._ <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 Or <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 />APPLICANT'S SIGNATURE: <br />PROPERTY/BUSINESS OWNERD OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT ret ir5Artien6A Camp. CronSu Itax•)- <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />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 <br />my representative. <br />-si <br />Re 11"14 TYPE OF SERVICE REQUESTED: r,„„i fooct in6pects-0Y\ Carpet) <br />COMMENTS: OR 2 7 <br />8-01 Joku j: 2°24 <br />ketviRo,vmecouivry 771 Do, Nrk <br />ARNENr <br />ACCEPTED BY: S . saiiehja j„ EMPLOYEE #: DATE: 4 . ,..,,I. <br />ASSIGNED TO: L. m u ro EMPLOYEE #: DATE: 4. a a . 3 4 <br />Date Service Completed (if already completed): SERVICE CODE: 0 (.0 I P/E: I (0 0Q <br />Fee Amount: I (I) a Amount Paid i R..0 2;-- Payment Date 4[221E4 <br />Payment Type Cajz ci, Invoice # --Cetti:1(3Creo 9/ g Received By: uty'd <br />DATE: q/-11. /1.4 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />-Tizmo .311g —1