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SAN JOAOUI�:OUNTY ENVIRONMENTAL HEALTF �3PARTMENT <br />SERVICE REOUEST <br />Type of Business or Property <br />A 1IEE.DE0. Izwvl -TL's. 3s0 To 2Ei'LAGE Ekl ftNb 116 -1 S0 <br />FACILITY ID # <br />BUSINESS NAME /0 O �,i E H E rI/�i�eJE� a i/ Tl j� /J <br />SERVICE REQUEST # <br />'r"LLtrSCo FAo11 iTt{ <br />52Z--5'(10 E,I•. <br />7j <br />Q -i5/ <br />FAx # <br />(GSI) <br />OWNER OPERATOR ti / ELLvI�.J 1= � 1 [� IST <br />CITY (Z. ! \Jl e ( Ur— <br />CHECK N BILLING ADDRESS❑ <br />FACILITY NAME N'( e LLOW f:- <br />DATE: 'J 1 3 G <br />Date Service Completed (k alre6dy Completed): <br />SITE ADDRESS 15 S <br />I <br />�ESGq aE <br />tZ.O Wli y <br />W �9 `f , J"l% <br />-r ZAGL( <br />95309 <br />Street Nmntrer <br />DE n <br />Street Name <br />Invoice # <br />City <br />zipcode <br />HOME or MAILING ADDRESS (N Different from Ske Address) <br />Street Number <br />Stmat Noma <br />Cm <br />STATE LP <br />PHONE #1 En. <br />(a�)Q33- 13 as S I St <br />APN # <br />o'I�_3— <br />0(eO-2-10 <br />i <br />LAND USE APPLICATION # <br />PHONE #2 ExT <br />)317 1 <br />BOS DISTRICT <br />s <br />LOCATION CODE <br />I 7 <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR �- `, <br />5 GO � ! /` V�� J I -y <br />A 1IEE.DE0. Izwvl -TL's. 3s0 To 2Ei'LAGE Ekl ftNb 116 -1 S0 <br />CHECK I( ILLIN ADD SS <br />BUSINESS NAME /0 O �,i E H E rI/�i�eJE� a i/ Tl j� /J <br />RecoluEn <br />SEP 13 2007 <br />ENVIRONMENT HEALTH <br />PIg g# <br />52Z--5'(10 E,I•. <br />HOME or MAILING ADDRESS <br />1:31CID M1%16o FSLA b, I STG <br />Q -i5/ <br />FAx # <br />(GSI) <br />3lpl- 4433 <br />CITY (Z. ! \Jl e ( Ur— <br />STATE G R <br />ZIP 9 2.50 cl <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; <br />COI MTV Ordinanre. Cndee Rtandardc. <br />APPLICANT'S SIGNATURE: <br />PROPERTY I BUSINESS OWNER ❑ <br />If APPLICANT is not the <br />and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />FEDERAL laws. <br />MANAGER ❑ <br />DATE: T T (q—1F'I II 10�' ,/� 1 / �. /� <br />e` <br />OTHER AUTHORIZED AGENWE%� HAAA(� <br />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._�.F ( <br />TYPE OF SERVICE REQUESTED: 5-7)A LC.. <br />A 1IEE.DE0. Izwvl -TL's. 3s0 To 2Ei'LAGE Ekl ftNb 116 -1 S0 <br />COMMENTS: <br />RecoluEn <br />SEP 13 2007 <br />ENVIRONMENT HEALTH <br />ACCEPTED BY: <br />�, C C i rij V <br />EMPLOYEE #: Z5 24 <br />` t <br />ASSIGNED TO: <br />I t i7 N '/1_ <br />EMPLOYEE#: ,-(� q 2.. <br />DATE: 'J 1 3 G <br />Date Service Completed (k alre6dy Completed): <br />SERVICE CODE: ( <br />PIE: W*„1-3 08' <br />Fee Amount: <br />W �9 `f , J"l% <br />Amount Paid Ig <br />Payment Date <br />1 13 Lo -7 <br />Payment Type <br />Invoice # <br />Check # '1D 2_(o �a cj _ <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />