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JAN JOAQUIN I.OUN'I T EN VIRONMEN'I AL it EAL1H IIEYAKI'MENI <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Std x-13 � <br /> OWNER/ OPERATOR ` ' <br /> V I ?_G 1 NI A I'�t t}(L'v)/J S CHECK If BILLING ADDRESS® <br /> FACILHY NAME v^AAg-T '•� <br /> / rOr. r IZ-Di2ElZ'Ty <br /> SITE ADDRESS &, )S- IlAJ 0t1_"TA •'rrV�• `T Kr'tGy Ifj04 <br /> Street Num bar DI JUo'n I Street NAMO NAMcityZi Co e <br /> HOME or MAILING ADDRESS (If Different from Site Address) (Pq cf -T Lk) , C rN, AL- B LO l7 <br /> Street Number treat Name <br /> CITY T�Rcy STATE Gia ZIP DjO� <br /> PHONE#1 1 EXT API# USE APPLICATION# <br /> 213 - /v0 - 3o /,//A <br /> PHONE#2 Exr. (STRICT LOCATIONCODE / <br /> al <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> -Aa'B 4 IZ/4 C C co CHECK it BILLING ADDRESS <br /> BUSINESS NAME L I IJ C 014c14­ C-C_0 EN V 1 RO N{K g.tuT^L PHONE# Ex . <br /> 201 <br /> HOME or MAILING ADDRESS FAX# <br /> r.�u�} w . o A1— ST. (2nd 1 3ro`I - 03� <br /> CITY L-t7,\ STATE �, R. ZP q52_40 <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUN'T'Y Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> -0 APPLICANT'S SIGNATURE: Q ` t 1 DATE: 6/-3y A3 <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ OTHER AUTnintizED AGENT pr <br /> IfAPPLicA,vr is not the B/LL/NG PARTY proof of autkorizadon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i5 available and at the same time it is <br /> provided to me or my representative. <br /> TYPEOFSERVICE REQUESTED: ��tE-W SVIeY r\CC •r Su$SL/J2f faGC CAN'Tf1W1l/V/M U�f {SLE Pp{2-T <br /> COM S: <br /> yMEIyT <br /> 8 /5�j (� ( tc(l �f C�vt w✓ I RECEIVED <br /> �bo'""5 ANN f 3 <br /> i ` l H��'ROHwvypir�"kYry <br /> ACCEPTED BY: EMPLOYEE#: ( _i ` DATE: <br /> ti / <br /> ASSIGNED TO: < ' 6,D 04.I rD EMPLOYEE ��D c>U ` DATE: <br /> Date Service Completed (H already completed): SERVICE CODE: 3 5 PIE: p <br /> Fee Amount: ,L 5� (}_:> Amount Paid Z50.00 Payment Date <br /> Payment Type V' Invoice# Check# 7/ T,�_ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />