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SAN JOAQUIPUItrbUNTY ENVIRONMENTAL HEALTH Dr/ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAME�A.tL*11,1 94 <br />SERVICE REQUEST If <br />rq.RS SIAnol'1 <br />a, EXT. <br />HOME Or MAILING AQDRESS <br />8 Vilatn Au -pe- <br />ASSIGNED TO: V /U FltiLic—: <br />FAX# <br />(1081) <br />OWNER/ OPERATOR <br />CITY &a N f 3�&-L <br />STATE <br />zip V11 .0 <br />Fee Amount:; C'V <br />CHECK if BILLING ADDRESS <br />FACILITY NAME S ^ <br />Payment Type 1,1-� <br />Invoice # <br />SITE ADDRESS <br />Received By: <br />Street Number <br />Direction <br />Street Name <br />CiR`N <br />2i Cotle <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT' <br />APN # <br />LAND USE APPLICATION # <br />(- pm 446- 9a%3 <br />173-vro.o-3s <br />PHONE #2 ExT• <br />( ) <br />BOS DISTRICT <br />l <br />LOCATIo CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />NW-eA4- •• • — N <br />CHECK If BILLING ADDRESS{C1 <br />BUSINESS NAME�A.tL*11,1 94 <br />los— <br />PHO <br />a, EXT. <br />HOME Or MAILING AQDRESS <br />8 Vilatn Au -pe- <br />ASSIGNED TO: V /U FltiLic—: <br />FAX# <br />(1081) <br />W3-60a.(o <br />CITY &a N f 3�&-L <br />STATE <br />zip V11 .0 <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 FEDERAL law' S. A J <br />APPLICANT'S SIGNATURE:: `,�U 1 � ,V - I/, .r l;ca tt4:A�.N:�......1 -DATE: 61 i' l aw lrf <br />/�/'� . _� <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT19 I�1h <br />CDIL(I a—ct 4'C'Cr•lg/ <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required C Tiile <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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: tP.'JT ttL <br />COMMENTS: <br />Qy�Sa✓ w1 d� she ttis ev b �alies JUN 1 4 2001 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />ACCEPTED BY: d C t v1 �t r� <br />EMPLOYEE M 032-4 <br />DATE: (o /L f 07 <br />ASSIGNED TO: V /U FltiLic—: <br />EMPLOYEE#: •d-'3�'7 <br />DATE: �af 0^7 <br />/ <br />Date Service Completed (if already completed): <br />SERVICE CODE: l48 <br />P I E: '2S08- <br />Fee Amount:; C'V <br />Amount Paid �g5 _ <br />Payment Date 6 /� 4,I U <br />Payment Type 1,1-� <br />Invoice # <br />Check # it 5-Z 1 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />