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SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTMENT <br />SERVICE RE UEST <br />Ty e of Business or Property <br />_ <br />FACILITY ID # <br />.._-, , 5 <br />SERVICE REQUEST # <br />0 c.... •-.? / c) S <br />OWNER! OPERATOR <br />LI .JCR moz E A c , at_z_ S <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />I-1-N T-F —C /1 <br />SITE ADDRESSrn <br />M <br />ico Street Number Direction ivokravicov_s --kg-ga I Street Name <br />tri,9"/Tcci-9 <br />City <br />9,s-.1.6 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />111$1E. As 16160o 6::. Street Number Street Name CITY <br />01 tql•-1 TE'Cll <br />STATE ZIP <br />r Aq _57 5-3-16 PHONE #1 <br />(20Ct ) 231 —"' I 29 1 <br />Exr. APN # LAND USE APPLICATION # <br />PHONE #2 <br />( I <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR SERVICE <br />REQUESTOR <br /> 1 K A C90 . 5 <br />_ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME _,... <br />,,et 1 At..1 oc-L_S <br />PHoNE# EXT. <br />Piaci ) 5143-80,95- <br />FAX # <br />(et) s-4/3- go C 8 <br />HOME or MAILING ADDRESS <br />C-9 9-2 P /2000,./ ,-.) <br />CITY ,,'" -, Jr-f L-1 illel STA16, ZIP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, 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 rformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, AT and FEDERAL la s <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER 0 PER. ' OR / MANA R C711 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BeLING 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 8tAttie tt,lcouNTY <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site -asvtism n pMpaTmEN1T <br />EWAL <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the samiktl <br />, <br />s provided to me or my representative. . <br />TYPE OF SERVICE REQUESTED: •t) 6 B b <br />CCIMNIM 0 0 Ge..4-1)E rvo-int 02A- (.4 toy. 6/ 2 S / P1 /4( IA 3 /4 Li_ 0 - c A.4 D I 1.1 sp tg To ti-LEET 4% 6 C6me_MAiLe <br />6) .Lti6T-zu_c_ 0 ciyrki /1ria-02S To (oArc,z6T--6 ,Occ / t /4200,4 4 fr.6)( LC3 To PNCI Afpni :S/ ,p Tvp 7 ) <br />ACCEPTED Y: kl , Peat 414,-11 EMPLOYEE #: ("c9— / 3 DATE: S., )S 1 ii <br />ASSIGNED TO: <br />ki Pe ) Ci -Z--61 EMPLOYEE #: (pd._ /3 i DATE: si. <br />Date Service Completed (if already completed): SERVICE CODE: 5D 3- P / E: <br />Fee Amount: _-- Amount Paid -{S;) ,g-z.) . 0 -0 Payment Date <br />Received <br />Vnt I <br />By:"Zet <br />Payment Type Invoice # Check # 2_2391 <br />-2 <br />/(" PAYMENT AL cEivED <br />AuG .1 2011 <br />EHD 48-02-025 <br />REVISED 11/1 7 /2 003 <br /> SR FORM (Golden Rod)