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c <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID 9 <br />S RVICE REQUEST # <br />I fLJr�k.l f.�l-/Sid t O F l I-1 (j <br />t <br />OWNER I OPERATOR <br />2 p ea 5 ES <br />CHECK H BILLING ADDRESS❑ <br />FACILITY NAME 4/EL1-olf:1 FILE I(�I� <br />ate'. <br />HOME Or MAIGNGADDRESS r' IS -)S L.JcAs V.,4t4c1a <br />SITE ADDRESS S3 <br />FAz>K <br />Mall <br />:FC',SC-A LjE <br />CITY F-A/JGHa WGAW tDA)&A <br />TIZA <br />zip 91 30 <br />Street Number <br />DIr¢ellan <br />Street Neme <br />Fee Amount: <br />CIZIRC.de <br />&b <br />HOME Or MAILING ADDRESS (If Different from site Address( <br />-7 19166 <br />u <br />Payment Type v-� S R <br />6hect Number <br />CheckA <br />Street Nam¢ <br />CITY <br />STATE ZIP <br />PHONEV OXT. <br />APN0 <br />-�'O JOG <br />LAND USE APPLICATION# <br />9a3i3'iHL <br />PHONE#2 E.T. <br />BOS DISTRICTLOCATION <br />CODE <br />ales1302 <br />-�- ?0 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />SN121.6N EAo112on1MG�AL <br />Gf�2P <br />CHECK U BILLING ADDRESS aL1I <br />BUSINESS NAME <br />yeA,,,-3 �Q'6l(�N I r <br />PHONE# <br />00 <br />ExT <br />ate'. <br />HOME Or MAIGNGADDRESS r' IS -)S L.JcAs V.,4t4c1a <br />� <br />1-1� ]'E 1pp <br />FAz>K <br />Mall <br />EMPLOYEE#: 2 �� <br />CITY F-A/JGHa WGAW tDA)&A <br />STATE CA <br />zip 91 30 <br />BILLING ACKNOWLED1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTmENr 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 appli a and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STA n FEDERAL laws. <br />APPLICANT'S SIGNATURE: 5. 11 GO DATE: �,"��OiO <br />I'ROPEFITY(BUSINESS OWNER C1 OPERATOa NIAI'1AGFR ❑ OTHER AUTIIORIZEOAGPm,Ir-PPcc{'�T' N,eNAb6Q <br />/jAPPLICANT is not /he B L NGP RTY proof ajauthorization to sign is required Title <br />AUTHIDRIZATION TO REI ASE I O : 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 ut the same time it is <br />provided to me or my representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />JUL 19 2006 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: ! <br />I <br />,,,//r l <br />EMPLOYEE 9! �r ( <br />DATE: <br />ASSIGNEDTO: <br />EMPLOYEE#: 2 �� <br />DATE: <br />Date Servlee Completed (If already completed): <br />SERVICE COON It <br />PIE: <br />Fee Amount: <br />Amount Paid <br />&b <br />Payment Date <br />-7 19166 <br />u <br />Payment Type v-� S R <br />Invoice# <br />CheckA <br />Recel d By, <br />EHD 48.C2-025 <br />REVISED 11/17t2Oo3 <br />SR FORM (Goklen Rod) <br />hih*d 9S62E1.L9T6T6:01 :wmu 9T:T2 9002-8T--inf <br />