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OAl\ JIIAVU11V I.VUPI I I J 1V1n"1VVIL`111HL 11.GHLlII LPiL HA�l IIAA`v1�1 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5�00(P4W <br /> OWNER/OPERATOR L /� - <br /> `C �O� t[ ��OK CHECK(}BILLING ADDRESS® <br /> FACXIIYNAME /'_VLVO�IVER— �(2-C- FN-P'r• �61�5 V <br /> SITE ADDRESS l(L7S-.&Le4 �. -I-EtzPcz-ts� (zL>• EcLRL,vrJ 9s32o <br /> Street Number Direct n Street Name city Zip Code <br /> HOME or MAILING ADDRESS (U Different from She Address) <br /> S O Number Street ante <br /> CrryO ` ST WE ZIS <br /> o.i[ � <br /> PHONE#t Exr• APN# LAND USE APPLICATION B <br /> (zo`f ) 9"- 13to1- 190 - to ppT-tloot35- <br /> P14ONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ikia-3q CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAMEPHONE# <br /> LLvG OPrtL C7'L�ENJl12-ONMEN7y4(_ E <br /> 2.0ri 13coti-o3fi� <br /> NOME or MAILING ADDRESS FAX If <br /> Fo-I w. I2-v9 ) 3(s`1- 03}} <br /> CRY Lp l STATE C,N ZIP 01 <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 /> 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 /> APPLICANT'S SIGNATURE: Id �. DATE: <br /> PROPERTY/BusmEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IRr PC'O�Gt 1 I\ay.wa a� <br /> If APPLJCANTis not the BILLING PARTY proof of authoriZadon 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 t0 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: 12' 41,t—W 50(L $U 1Tak" I LA TJ ! N t L K'b(/v V- STV bJ <br /> COMMENTS: I—/,('7' <br /> 7 Ib PAYMENT <br /> RECEIVED <br /> (ot qv& MAY -2 2012 <br /> SAN JOACUII G UIRY <br /> � <br /> �f - EWRONMEM <br /> i HEALTH DEPARTMEK <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: .jJ EMPLOYEE#: •"-/Q Ys DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 2� PIE: o Z <br /> Fee Amount: 6 ' Amount Paid ( :2 Uj Payment Date L �� <br /> Payment Type x Invoice# Check# ` Z-- Received By: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />