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COMMENTS: Reira t / 1:4 Ai ()del 'Pla n c-,beci6 <br />ACCEPTED BY: A t.4 <br /> <br />EMPLOYEE #: <br /> <br />ASSIGNED TO: Vidal ve draza <br />Date Service Completed (if eke, dy completed): <br />SAN JOAQUIi., COUNTY ENVIRONMENTAL HEALTH 11,-ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />0o\7_\12, <br />SFRVICE REQUEST # <br />S12-007N9) <br /> <br />OWNER / OPERA.TOR .Wo <br />I iCt"Y fr ess CHECK if BILLING ADDRESS <br />FACILITY NAME <br />/ <br />SITE ADDRESS Trcicy Ake/. st Stree Number 1 Direction Street Name <br />I ,1F Or 7 ANG ADDRESS (If L Tfkrent from Site kddressI <br />Street Number <br />t;ITY STATE <br />-Tr trc <br /> c(5-901 <br />ZI C :e <br />Stir .t Name <br />ZIP <br />PI ONE #1 <br /> EXT. APrl # L.f,AD !PIE APPLICATION # <br />BOS DIS TRIC LOCATION CODE <br />CONTRAC1 OR ./ SEM; REQ UESTOR <br />RI_QUESTOR <br />r PC11 *()) ki 5 j-er, r/19 1<y/: rf pitiECK if BILLING ADDRESS <br />BUSINESS NAME <br />PH. IE #7 <br /> EXT. <br />PHONE # EXT. <br />(2 6') SC/'9'.. / <br />HOME or MAILING ADDRESS - 0 At F-Acr 1-r( FAX # <br />( ) <br />CITY (FT) n STATE 4 ZIP <br />675 <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-ind F E AL laws. <br />APPLICANT'S SIGNATURE: -,%"-Z /7 • DATE: <br />PROPERTY / BUtilNESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT ic nr.1 the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: WI n applicable, I, the owner or operator of the property located at the above <br />site address, hereby authorize the release of any and re6ults, geotechnical data and/cr environmental/site assessment inform on <br />AW441 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to Mr <br />my representative. Rpe r- air ,c11/E-r, <br />9 20/6 <br />sAN 40,40 <br />Et4 <br /> <br />q,1 OLIN ALI DCE kNrilk TY Ant/140yr <br />TYPE OF SERVICE REQUESTED: 444 )./ <br />L. <br />EMPLOYEE #: DATE: <br />SERVICE CODE! sc 5 FE - 3(12 02 <br />DATE: <br />Amount POI? 026, 0, OD Payme It Date <br />Invoice # 474 <br />Fee Amount: ‘2 0. 00 <br />Payment Type <br />END 48-02-025 <br />07/17/08 <br />ci-HQ—ot - 3,3 y,s7 Received B;1-7 <br />SR FORM (Golden Rod)