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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�-vui 5a s3 <br /> OWNER/OP PATOR _ `LYI c / ,1 <br /> I 0 NJ S I A } �O N ^ t JU E SI LVA CNEix If BILLING ADDRESS <br /> Fa-_ITYNrp;, TbII S(LVA - SOrvS bAie-1 ----- ---- --.. <br /> SITEADDRESS 73l-6-0 ^J .�fkCIG 7prJC �`p , AC Rr"^ POS <br /> q aw <br /> __ _,,.sheet Number Dlreetlon Street Na,, _ .._ .:IN _ - Zi Code <br /> idE )r P.` " <br /> ' MI '":DRESS (If Different trori Sue Address) ..~7-3490 TN, ., IC- 70NL r2-17 , <br /> Street Number <br /> lry � AwtPd Srare ZIP �fS azo <br /> PHONE#1 Em APN# LAND USF.APPLICATION# <br /> (Zc�11334- 11(o&k ozI - Oso - I q A4 - /& - SSG ) <br /> PHONE#L c'T BOS DISTRICT LOCATION CODE <br /> (7�e11_ 9 - 3a � F — <br /> _ CONTRACTOR ir SERVICE REQUESTOR <br /> REQUESTVR <br /> A,3 9y P-ftCC a CHECK If BILLING ADDRESS <br /> BUSINESS NAMEutvu VNL �0F-6 p�jNmtNTRL_ PHOv ) E:r. <br /> Y� Z"i31- O'2)�-S <br /> HOME Or MAILING ADDRESS O AV- S'T- FAX# <br /> CITY �� ( STATE C1"k zip d(�2`{O <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 /> 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 perfornI will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws <br /> �.PPLICANT'S SIGNATURE: W&I '-' � <br /> DATE: <br /> � <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED ACENT oNS VL-TA^'F <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZ',TION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the p,operty located at the above <br /> site add: v, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SA' JOPOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same P:me It Is provided to me or <br /> my representative. �, <br /> TvPEOF SERVICE REQUESTED: 6-/�T lcv,) 5'U9,6-1r-C5-IFSUeAFACE C0t-r4AW1A1A- vr- <br /> COMMENTS: &-Y L/ /K����..J�'1 TftL R.WN.IM/ CES ED <br /> ni r CscC »r t r 42 <br /> JUN 1 5 016 <br /> �tQfli i� SgNdOgO <br /> HEAINTH��vEN CNry <br /> ACCEPTED BY: L�/y//J Ei.I PLOYEEV DATE: ENr <br /> ASSIGNED TO: ✓r EMPLOvEE#: F'7j DATE: <br /> Date Service Compietrd (ifak: dycompleted): Service CooE: PIE 03 <br /> Fee Amount: g r�� Amount P �i� ��, — Payment Date <br /> Payment Type .voice# Check# Received By- / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17108 <br />