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SAN JOAQUOOUNTY ENVIRONMENTAL HEALTHOARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7-5-71 5'2 b <br /> OWNER/OPERATOR SAntbeF)9 S/NG4Y <br /> �I CHECK If BILLING ADDRESS 59 <br /> FACILITY NAME n n `1 <br /> A n� PrM PM <br /> SITE ADDRESS S ss ) LC Tulle <br /> 99 6, FAD 4 sp *Lh" q5 2-1S <br /> Street Number D <br /> Street Name CI ZI Codo <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> ( ) g4t �2438 174—Zoo-Sf <br /> PHONE#2ogE". BOIS DISTRICT LOCAno CODE <br /> ( , X06 -qiu � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R.EQUESTOR 9l)1,4r,'�6-e- S/NGH CHECK If BILLING ADDRESS <br /> BUSINESS NAME /t 11/' H -A A r .. (��t JC,f,,,(0 �O 1 /�9 /� [1 PHONE �QrL EI"' <br /> HOME or MAILING ADDRESS I J�i'�l-.v )Tr^)^'r akp- ALPQ -/ / G. Yw ,p�r� ",I) <br /> 2C q U b <br /> 1.� K-I ) <br /> CITY („G� 1�N /�J STATE 0?r ZIP <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 ap lication and that ftwork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S TE and EDERA/L�j�j\ws. <br /> APPLICANT'S SIGNATURE: S,��Y d . DATE: DI- OS - 201 0 <br /> PROPERTY/BUSINESS OWNER pt OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICAA'T is not the BILLi1vG 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 <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. T <br /> TYPE OF SERVICE REQUESTED: (��T 0,4E-r)"F 1 1 At- <br /> ,NI <br /> ``� <br /> COMMENTS: � V <br /> Nj <br /> ii?EP r-1 iL beEPLA-C 6' A-v'Z l o I V l JI A-L ht R-AA4 Pd/L VC 5 2010 <br /> 61162 PILL 10k a�INCou n <br /> sPENV.�pEPPP` Nt <br /> ACCEPTED BY: b L I EMPLOYEE#: 03 X-I <br /> DATE: / <br /> ASSIGNED TO: V O AJ FLLL F- I EMPLOYEE#: iT j 1`7 DATE: I <br /> Date Service Completed (if already completed): I r/E: 23 o? <br /> Fee Amount: 3 ��' Amount Paid 3 5 .. Payment Date !, ,D <br /> Payment Type ✓ Invoice# Check# \136 Received By: IN&- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />