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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR /.�� C CHECK If BILLING ADDRESS El <br /> / ,� /`�o Ari .� ws <br /> FACLLRY NAME -4 <br /> _ <br /> l.ai'C 4 YtT t O c. n .. <br /> EADDRESS'ypf„x W6g2 V.- 61f0A eA a.,J-e- <br /> Street Number Direction Street Name <br /> C Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Ce., Ter Street Number Street Name <br /> CITY FL APN# STATE zip <br /> 5750 <br /> PHONE#1 <br /> t r� ♦•rlrl B LAND USE APPLICATION#E'Ir• <br /> (g2Z5) 2-q5 3600 , ZOq -ogo — <br /> BOS DISTIU LOCATION CODE <br /> PHONE#2 - Cr - <br /> ( 2l 7,43 A <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS Lr,J <br /> r��/I / PHONE# E> . <br /> BUSINESS NAME (' _ n 1 C� a f'"1 -ee1/l 1'2 0 n Z(1 - Oslo <br /> 1D S FAx# _0539 <br /> I'IOME Or MAILING ADDRESS (.� ) 2-� i. <br /> CITY L HL. STATE 1--A- ZIP 9 S -0 <br /> J OG4 rlT n <br /> BILLING ACKNOWLEDGEME : I, the undersigned property or business owner, operator or authorized agent of same, <br /> HEALTH DEPARTMENT hourly charges associated with this projector <br /> acknowledge that all site and/or project specific ENVIRONMENTAL <br /> 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 /> 1, - <br /> APPLICANT'S SIGNATURE: DATE: Oz/l, �� ���/// <br /> rr��77 Cdn S++I�4it � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Ja Title If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <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 /> rCOM�MENTS <br /> SERVICE REQUESTED: W e- f 1 p,n <br /> : PI P-0.SQ f�G V e IW �GFD�vvt.ty Z7, 2L)06 l erg <br /> ht [ ,ps — lnAv� Gl �V�t .iw� e � 9w-s ✓4910 elostn/L°-/ 4IA (( 1�of6r 1Te .Sjwrcft a, ra well Glos"/c .xcce�Tanr� , RECEIVED <br /> PR 2 2006 <br /> _� EMPLOYEE#: r^ DATE' IN COON <br /> ACCEPTED BY: w <br /> ^ n DATE: ENVIRONMEN <br /> ASSIGNED TO: EMPLOYEE!� l �� (/ L TH DEPARTME <br /> SERVICE CODE: zZ P I E: <br /> Date Service Completed (if already co a d): <br /> 3� <br /> t Paid 4 <br /> Amount c7. Payment Date , <br /> Fee Amount: ( � I�L- D <br /> Check# Received By: <br /> Payment Type Invoice# 'jC3-o �o <br /> SR FORM(Golden Rod) <br /> EHD 4S-02-025 <br /> REVISED 11/17/2003 <br />