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SAN JOAQUIr} JUNTY ENVIRONMENTAL HEALT-EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> DA 12 A C u t-ruR Ar 1 ^-t1 <br /> OWHERI P RATOR CHECK if BILLINGADDRESSD <br /> DAnlI� L �. RUGf,�A <br /> FACILITY NAME 1J A N/v Oe-F{A -PA//Z <br /> SITE ADDRESS W AAHO'e 7-A,44- yX304 <br /> 65-5-1 Street Number Direction Street Name city Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> T• 1213 <br /> APN# �7 ^17 2 LAND USE AP`PALICATIONPHONE#1 -000-2. oc 7 a a� 1v/I" <br /> 1 1 3Z� � S� <br /> PHONE#2 ExT• BOS DISTRicT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR DO Al Y CHECK if BILLING ADDRESS ry <br /> BUSINESS NAME PHONE# Exl' <br /> r 44, -11a-3 <br /> HOME or MAILING ADDRESS FAx# <br /> O. Box 31f--4— ( ) <br /> CITY L O G STATE CA zip �1�30 <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 or <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I]lave prepared this appli ion and that a work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STT and FED s: <br /> APPLICANT'S SIGNATURE: DATE: 3 -2f—o <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ NAGER ❑ 7orization <br /> R AUTH0RIzED AGENT <br /> If APPLIC.tNT is not the$ILLINGPARTY,proof Of aut to sigh 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 REQUESTED: A//rltATc LOADllytf .41N/b 5-414, s'wrl 91'4/7971no/,--S PAcac=cle <br /> COMMENTS: /0 A/V GC/ZE /14 ev'A4 H/"rE N 7/V.'R/V 1Z ErV1i=-W �nQ�t <br /> Y- �lr 3�2 MAR GU �o� <br /> r P'N 3QAOUtM-'-WAt- <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: jd DATE: 3 aCj b <br /> Date Service Completed (if already completed): SERVICE CODE: x5sa P!E:o`)(p� <br /> Fee Amount: 5 -t� Amount Paid 1 Payment Date <br /> Payment Type ✓ Invoice# Check# g-g' Received By: <br /> END 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />