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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> CRANE 0,PERA7-f0Fr C3USlNE55 S5 OC(oS3.74 <br /> OWNER/OPERATOR 1}' <br /> P-2R • KEITH OWED L CHECK If BILLING ADORE53LJ <br /> FACILITY NAME <br /> /YJERICAAf C',•2/-ln/E RE/VTAL /NC• /y, <br /> SREADDRESS /700 /Y/A0 S COry/Cv.J6JC n/TecA 9x336 <br /> Strmt Number Direction I Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> F.• 0 . 15 ox 30Street Number Street Name <br /> CITY 5CCA G OAf STATE n^ ZIP fS3 2O <br /> PHONE#1 ✓ / ExT. APN# LAND USE'APPLICATION# <br /> 0,9f ) G��- 53s� 20 _ -a3 /Vor iSsreo <br /> cEi <br /> PHONE#2 ECT. BOS DISTRICT LOCATION CODE <br /> (aoy , 03e - ii3vi,5 i I — <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR // <br /> o/� G�/r tC SFI E CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr' <br /> PROVOST PRl-T-CI-IA9-D e0^4f6!LrIA1 doy gO - a300 <br /> HOME O-q'7 <br /> AILING ADDRESS FAx# <br /> 7O/ sls/< 1';1,91 ) <br /> CITY 1'nOD ej-ro STATE C.A ZIP q5 3 5-& <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 <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 ton and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S and FED ws. <br /> APPLICANT'S SIGNATURE: DATE: 7-23 - 17—7-1 3 - /Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ 'AGER ❑ OT R AUTHORIZED AGENT OD <br /> If APPLICANT is not the BILLING PARTY proof ofaulhori ation 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 environmentaUsite 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: nl/rRArE LOADIA/ SO14 J"17-AB/AfT SrWD RSV1JFVV <br /> COMMENTS: <br /> RECEIVED <br /> JUL O 23 2012 <br /> l / N COLI <br /> EMIIRONNI[ TAN_ <br /> ACCEPTED BY: EMPLOYEE M © ATE: 2-3 t . <br /> ASSIGNED TO: T/�5 t apeG�(oS EMPLOYEE#: /1 Z3 Z <br /> Q G�S DATE: -7 t <br /> Date Service Completed (If already Completed): SERVICE CODE: SSS PIE: 2-(�p 2. <br /> Fee Amount: . `� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />