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SAN JOAQUIN . ,)UNTY ENVIRONMENTAL HEALTH L-_ ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />s <br />C' A& rATLO cJ <br />PH NE <br />�6l <br />J L(O <br />HOME or MAILING ADDRESSFAX <br />3aa`f <br />/q -7 o7 <br />OWNER/OPERATOR �^ <br />S � \LW 0. t ` l+�C • <br />CHECK If BILLING ADDRESS <br />FACIUTYNAME Sf__ f- wa <br />STATE CA <br />SITE ADDRESS /. Y 1 �.-c <br />10 �tStreet <br />I <br />P / E: <br />J <br />Amount Paid aCt).� <br />Number <br />Direction <br />Street Name <br />Invoice# <br />cityl <br />Zip Code <br />HOME Or MAILING ADDRESS (if Different from <br />Site Address) �-Q f % <br />S., mer ,&y �(� `cL . <br />u `^� <br />Street Number <br />Street Name <br />CITY Tt-ea�4vvi <br />STATE lq ZIP <br />T o CC <br />PHONE#1EM <br />(9:RV 4J4� :x707. <br />APN# <br />- <br />LAND USE APPLICATION# <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />Z <br />LOCATION CODE <br />`� 0/ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR'n�� <br />Ll T4� <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />Pblte F �aifL�eLtat�ee 3 r`c. <br />cS'�C�DII�UL c�L�L1�L:� D�L7 ZO <br />DEC 0 7 2007 s JOAOUIN COL <br />EivRONMENT <br />ENVIRONMENT HEALTJALTH DEPART <br />PH NE <br />�6l <br />EXT. <br />ad3- 603 <br />HOME or MAILING ADDRESSFAX <br />3aa`f <br />/q -7 o7 <br /># <br />(4t 4) <br />W3- !00 b <br />CITY Seg..la-+C[ RD &CL, <br />STATE CA <br />LP <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operatoror 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 laws. <br />APPLICANT'S SIGNATDREi U <br />DATE <br />PROPERTY/ BUSINESS OWNER[] OPERATOR/ MANAGER ❑ OTHER AUTHORIZEDAGENTIV <br />/,fAPPL/CANT is not the BILLING PART}' 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. <br />TYPE OF SERVICE <br />(R'EQUESTED: <br />COMMENTS: V� IfCllfS I _"'tID.L��I� <br />cS'�C�DII�UL c�L�L1�L:� D�L7 ZO <br />DEC 0 7 2007 s JOAOUIN COL <br />EivRONMENT <br />ENVIRONMENT HEALTJALTH DEPART <br />ACCEPTED BY: OC -c I.Etl2-A <br />EMPLOYEE#: C)32( PERMIT/ <br />/q -7 o7 <br />ASSIGNED TO: 6A cl a- lS <br />EMPLOYEE#: 4(a 3.6 <br />DATE: / <br />Date Service Completed (if already completed): <br />SERVICE CODE: (�j (� <br />P / E: <br />Fee Amount: zq �, to <br />Amount Paid aCt).� <br />Payment Date <br />0 <br />t 2,111-7 <br />Payment Type E/ <br />Invoice# <br />Check If 2_-S3 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />NN <br />IL <br />ENT <br />