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DAN JOAQUIN I:OUN'I'Y VNVIRONMEINI'ALnEALIHIIEr"11VIE14t <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE <br /> /REQUEST# <br /> �A/Pgsn%zr LL5W�J(Gt/�. <br /> OWNER/OPERATOR <br /> 1)9,9P VALE ROPER-T/ES L6G R. M/KE /ZEfTQ CHECK If BILLING A0DRE53 <br /> FACIUrr NAME <br /> EST- kArR90P B9511VE-65 PAtZW- <br /> SIEADDRESS MAA/THEy SOKrf/ ATf/RoP 93'330 <br /> 101033 Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 13 3 4507-14640 ,AVE. Street Number Street Name <br /> CITY STATE ZIP <br /> MHLP/TA (A 93035- <br /> PHONE#t APN# LAND USE APPLICATION# <br /> (409 ) 26Z - 1410 / - 230 - - 64 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> IryS00 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Q Intx SNE CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ea"' <br /> E <br /> C NE CoNSUc //v 668-f4a3 <br /> HOME or MAILING ADDRESS FA%# <br /> P. p . ( ) lo(o8-ZS9 <br /> CITY R` /` STATE ZIP S39/ <br /> BMLING 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 /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this appAcation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, t E and F laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of thorization 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: 7V/TRA TE SBA D/N SO/IA T BIIi Ett/ <br /> Q MVRTS-ov ilge- 4 "`' lY RECEIVED <br /> �cfldlE`i �cl _ <br /> t�TJ r <br /> MAY 2 2 2006 <br /> 00� d.� 3�r`i 0-'_ <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: 3 DATE: <br /> ASSIGNED TO: I EMPLOYEE#: JT DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: G ZjSI P I E: 7i <br /> Fee Amount: Da Amount Paid G�.; Payment Date 5 1,2,7-1 <br /> (� <br /> Payment Type Invoice# -aS 3'L Check# Received By.� (_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />