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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> / GTGIlLAL �20o c+ 9 30 <br /> OWNER/OPERATOR <br /> CHECK 1(BILLING ADDRESS <br /> 0 <br /> FACILITY NAME <br /> ac�ri AR <br /> SITE ADDRESS 69O WE 5T- �jQ p//ry,Q/✓ FR>tNcf/ L'i'i-r+7P �/S3�/ <br /> Street Number Direction Street Name city Zia Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APP ICATION# <br /> V09 ) I93 - 17,22-. /9 - 2Go - 2 1 4 -7 �- 2 - ,(,r <br /> PRONE <br /> #' EXT. 11 LOCATION CODE <br /> (10 ) 4gZ 696 T&. I <br /> CONTRACTOR/ SERVI -5-1-Q— amass ,�tS <br /> REQUESTORff <br /> DoN G#&�s vfA-A/rt�w .— O�4 - ���-t 8 C.,s� 5 <br /> BUSINESS NAME ^Ar5 . /' �O� `�L VC (,.L r-rr44[G� [.– 4%,-, G�d; T. <br /> G /VG /v WQS VC. .cut fij fes^^ t <br /> HOME or MAILING ADDRESS P D, Y/v t.: --3l <br /> CITY � R � /— <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEA project or <br /> activity will be billed to me or my business as identified on this form ( ez u L-c C -'-e- <br /> I also certify that I have preparedthis app cation and at the work tc �c O.0 (o` 1 (D ' d JOAQUIN <br /> COUNTY Ordinance Codes,Standards, and F L laws. <br /> APPLICANT'S SIGNATURE: -- vA-rEr <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLIcANT is not the B[LLING PARTY proof of authorization to sign is required Titre <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:-�;IAIF FA CEI aA F / R ✓/,_ <br /> COMMENTS: REC IVED <br /> JAN 1 S 2007 <br /> SAN JOAQUIN COLI T <br /> ACCEPTED BY: ✓O EMPLOYEE#: / DATE: ` <br /> ASSIGNED TO: !n EMPLOYEE#: 7� DATE: <br /> Date Service Completed (If already Completed): SERVICE CODE: P I E: <br /> Fee Amount: Amount Paid ! O Payment Date l I /;,. <br /> Payment Type ✓' Invoice# Check# �-(o L{ G Received By: , <br /> EHD 48-02-025 -,SR€dF�NF'jtold€11'Rod) <br /> REVISED 11/17/2003 <br />