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(O op <br />08/22/2006 13:42 9094767114 SHIRLEY ENVIRONMENTL PAGE 02/02 <br />N.. <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />=,SE�7FWC�.ER�EQUEST� <br />OWNER OPERATOR <br />coaNENra: e�0Q-e <br />�/7� et^-��// <br />k,—' G N J e� a rS� S <br />CHECK If RILUNa ADortess L-1 <br />FACILITY NAME <br />AJ LA/ae C 7(G <br />SITE ADDRESS FZAIf Pes t a{t- ale 4 D <br />5-37 s <br />ISANJOAQ <br />umbar DInen tree <br />HOME Or MAILING ADDRESS (If DlNarent from Site Address) <br />Cote <br />Ar <br />r <br />Numher <br />CITY <br />Dut,�/�,..� Oa..,r` <br />STATE ZIP <br />L <br />2I <br />PNONE#t Est7 APNO <br />LANn USEAPPLICATONS <br />(J/rl3w- 36y <br />PHONE 92 Ezr. <br />(2 33-/S^7 <br />FIM f: <br />Hos DsrHlcT <br />LoeanoN Cooe <br />CONTRACTOR/SERVICE <br />RECIUESTOR <br />CHECK If HILUNG ADDRESS <br />BLISINEss NAME s / / ✓"^u` - PNONE# <br />.�_ <br />HOME Or MAILING ADDRESS / FAx# <br />9s 4r L a+e. S Wwo.r. z Q dt --&-L i^ a_or i <br />- <br />STATE .1 _ _ ZIP .n _ <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 />1 also certify that I have prepared this application and that the work to be performed will be done in accordance with ail SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE, and FE•DERA:. IaWS. <br />APPLICANT'S SIGNATURE: , DATE! r- 21 —D( <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER A=oizirro AGENT 0� <br />Ifis not fhe KILLING PARTT. /JPOOjOjaudterilallOn to sign is required Ttr <br />AUTHORIZATION TO RELEASE TNFORMATION: 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 />InfOnnatiOn to the SAN JOAQU N COUNTY ENVIRONMENTAL FIFALTH DEPARTMENT as soon as it is available and aR the sante time it is <br />provided to me or my representative. <br />TME OF SERVICE REQUESTED: <br />coaNENra: e�0Q-e <br />o intd <br />AJ LA/ae C 7(G <br />Ori �� . /L 4 u v o /� T.0 <br />ISANJOAQ <br />ACCEPTED BY: <br />FIM f: <br />DATE: <br />O <br />ASSIGNED TO: <br />O <br />EMPLOYEE #: 6 <br />DATE: <br />Date Service Completed (If elteady oom ltd): <br />SERWA CODE: ` <br />PIE: <br />Fee Amount: S <br />Amount Paid <br />2�S 0 <br />Payment Date <br />Z O <br />Payment Type 15 <br />Invoice# <br />-B �(3.zg3 <br />Received BY: <br />EHDI�v�IRn` <br />REV 4ED 1111 SR FORM (Golden Rod) <br />REVISED i U17/2o033 <br />TENT <br />IVED <br />2 2006 <br />N COUNTY <br />MENTAL <br />'ARTMENT <br />