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JO) <br />SAN JOAQ60 COUNTY ENVIRONMENTAL HEALTH 7 PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK If BILLING ADDRESS Im <br />FACILITY ID # <br />SERVICE REQUZST # <br />Gas st�fiow <br />�' <br />t 55�f <br />R o o 9 <br />OWNERIOPERATOR �' r!/L1/��/p�f"'}1—'1� <br />I✓!f I , ^� ! I " y lC�/\ <br />a i%l1 <br />('l t ! <br />c7 to � <br />CHECK If BILLING ADDRESS <br />FACILITY NAME fi57 ne cts y i <br />Lu��PrN�/ 1Nt <br />ACCEPTED BY: <br />SITE ADDRESS ¢U N <br />J- <br />w� <br />lffpGT <br />/ <br />�e tr <br />GI/Fr7 <br />$T�Ck9oN <br />"S -9-01-f <br />Street Number <br />Direction <br />Street Name <br />CRY <br />Zip Code <br />HOME or MAILING ADDRE�SS�j(If�D7ifferent from Site ,dddress) <br />PIE: <br />Fee Amount: <br />Amount Pai <br />Igoe, / /�/� 1A �m U <br />Street Number <br />Payment Type <br />Street Name <br />1p <br />CITY S bC �d� <br />(,.� <br />STATE e/q ZIP CISr� <br />-L/2i <br />PHONE #1 EXT, <br />i 4-�*— (-S-Li S <br />APN # <br />LAND USE APPLICATION # <br />PHgO�NgE #2 ^ ^ ^ EXT <br />/ �, NIG cl-f <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR �.r I. fl. /r ] w �o f= yl G �' -/ IJ <br />J U [ I'7 JLil1 c7 `1 /f <br />CHECK If BILLING ADDRESS Im <br />BUSINESS NAME o,s-T I—os\l Inop-r <br />l�if�7�.7/K <br />SL <br />'99 <br />PHONE# n�— 13-L1 <br />-1� <br />HOME or MAILING ADDRESS <br />7 C 15I <br />�' <br />n <br />(�) <br />CITY 7G e�w <br />STATE i'6 ZIP <br />BILLING ACKNOWLEDGEMENT. I, the undersigned properly or bus no, <br />acknowledge that all Site and/Or prOfeCt specific ENVIRONMENTAL HEALTH C �� � �'(�� 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 F _�.ya�� v SIN <br />COUNTY Ordinance Codes, Standards, STATE FEDepaL laws. _ I (�ti�i/ f(/ f � <br />APPLICANT'S SIGNATURE: d/��'( [gf,•7rf/41 U {J f `-"l <br />PROPERTY I BUSINESS OWNER E OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same 114 �vide`d to me or <br />my representative. i-C.."':iRl, <br />TYPE OF SERVICE REQUESTED: / rZ. /„ !'Q rQ% <br />O <br />COMMENTS: <br />SAN %(7 f4 <br />f1Eq tiQ <br />L <br />E <br />ACCEPTED BY: <br />DATE: JL+ <br />ASSIGNED TO: <br />#EMPLOYEE#: <br />#: W <br />DATE: d "7 / <br />C/ <br />Date Service Completed (if already completed): <br />/ <br />SERVICECODE: / / <br />PIE: <br />Fee Amount: <br />Amount Pai <br />�75; p <br />Payment Date j Zcl <br />Payment Type <br />Invoice # <br />Check # 20 Z <br />Received By <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />Ic <br />