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\ JANJOAQUINCOUNTY LtNVIKUNIVIENIALnrtwrnLErAnAllt�INI <br /> SERVICE REQUEST <br /> Type of Business or Property _ FAC,_ITY ID# SERVICE REQUEST If <br /> ZD� uSTR(AL <br /> OWNER/ OPERATOR CHECK If BILLING ADDRESS❑ <br /> /n,PP PROPERTIES PRE5TONP/PE1-/1VE5 llnlKF XEfTON <br /> FACILITY NAME <br /> ME5T L-ATLfP-oP 9 U PNE55 <br /> SITEADDRESS /'2 87 four{•/ /+'/.4A/Tl(Ey/ 4A7f42oP 9�3.J0 <br /> Streel Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1,33 r/{EG p <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH NE#1 EXT. APN# LAN USE APPLICATION# <br /> ( 081 5 - ZZo — -o N --Oyu ley <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> - (gyp CUES � <br /> BUSINESS NAME PHONE# EXT' <br /> G,�I�S�vE foitlJu�r N 1068_ o_7 <br /> HOME or MAILING ADDRESS FAX# <br /> 70. R5I>r 3794 ( ) (oG8-zfQ� <br /> Cm ax L OC/G STATEeA ZIP ` 7/t/ <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 projector <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this app ' ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and F L laws. <br /> APPLICANT'S SIGNATURE: DATE: w _ 7-0jr- <br /> 3;' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLicANT is not the B/LIING PABTP proof of authorization 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: G N 9EVIEW - YMENT <br /> COYME{/(NTS: J I JUN Q 2006 <br /> SDI �14(J�r f ` SAN JOAQUIN COUNTy <br /> U <br /> Y.- VIR <br /> %Ej� DONM ENTAL <br /> PAR MEN)' <br /> ACCEPTED BY' EMPLOYEE#: DATE: 6 <br /> 1/1 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECoDE: 52 -Z_ P1E: <br /> Fee Amount: Amount Paid $ �, �j Payment Date <br /> Payment Type .% Invoice# y Z Check# Received By: (� <br /> EHD 48-02-025 SR FORM(Golden-Rod) <br /> REVISED 11/17/2003 <br />