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SAN JOAQUT'-`-�OUNTY ENVIRONMENTAL HEAL'P EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A RILuLTu2Ae-leFrlDENT/AL 14SIIC00443OZ5/o <br /> OWNER/OPERATOR p* �, f!f <br /> /� A . 1WAF1- VIA/ b✓ELeH 1 � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 57 /C/ DIETRIc{-l- /Mp EN ?rz 3,6 <br /> Street Number Direction Street Name city ZiD Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE LP <br /> PHONE#I ` EXT. APN# LAND USE APPLICATION# <br /> I ) I /05- 2/D-2o e 2/ /fA -05 - /9.5 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C CHECK If BILLING ADDRESS <br /> BUSINESS NAME /'r rvL PHONE Ear' <br /> E NE CONIU c T/N 9- 3 <br /> HOME or MAILING ADDRESS FAX# <br /> P © • 3714 1 1 ) �O69-Zs1B <br /> CITY GL 2 L OG/C STATE CR ZIP �f3 <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 /> alctivity will be billed to me or my business as identified on this fomL <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,StandarMSand aws. -7 <br /> APPLICANT'S SIGNATURE: DATE: / - 13-0-5 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR iMANAGER ❑ HER AUTHORIZED AGENT <br /> If APPLICANTisnotthe BILLtMGPARTY proofofau orization 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 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: SO/L SGI/ L r fu A Eic '�U1 "-✓/�kl <br /> COMMENTS: Pf� e�.+ �(�pq RECEIVED <br /> ee �" r RUSH JUL 13 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#:©g// ATE: �r <br /> ASSIGNED TO: ^ EMPLOYEE M O / DATE: <br /> Date Service Completed (If already com t ted): SERVICE CODE: 5'z Z P I E: �6,p 2-- <br /> Fee Amount: j77, C Amount Paid 9372 Payment Data <br /> Payment Type „' Invoice# Check#�3 Received By. !LJ1�- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />