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JAN JOA41U1N I:UUNTY LNVIRLINXEN'I'AL nEAL'IH VEt'PAKI'ME'N I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# p SERVICE REQUEST# <br /> S2zi�&.a S;11 <br /> OWNER/OPERATOR <br /> emtt_ tJAJRf=tZP. CHECK i1 BILLING ADDRESSED <br /> FAcu"NAME ffAJAfZftA Plc<''ER'nES <br /> SITE ADDREss A4'1 5' 1 v . RaLiwE'TT -V 34-'T9 D T. KdST 'f {z,Rc:� 1153::4 <br /> treet N',-h, Street Nam CRY Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 14-4,5- <br /> Street <br /> 4-4SStreet Number StrootN e <br /> CITY -T g-p%'L4 STATE C_ ZIP <br /> PROMEM EXT. APN# LAND USE APPLICATION# <br /> ZSR-I'� u - GI <br /> (244 ) 93(9- 0005- 1 -L%� - 1-M -I c <br /> PHONE#Y EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR R03�i PSCC-c7 <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME L-1vt pP�IL G�-y'UE�J1(LSNWt✓GN"iAL PMNE# Ems. <br /> 20`1 <br /> HOME Or MAILING ADDRESSFAR# <br /> 40"} ta, oPcK S'T. IzUh) 31rF1-o3�� <br /> Crtv LU1>1 STATE Lp, ZIP ols'x } <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: tMA4 P< DATE: <br /> � �i ' 1(o–( I <br /> PROPERTY/BUSINESS OWNERO OPERATOR/ ANAGER ❑ OTHER AUTHORIZED AGENT 1pp (-SrJ5VL-71kr-Jr <br /> ifAPPLtcAAT is not the B/LL/NG PARTY proof of aulkarizadan 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 CODNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time it is <br /> provided to me or my representative. <br /> TYPEOFSERvicEREQUESTED: A-J,%/tEDJ $JR-FACE JBS L12Ff+C-� C-�r✓fl4 N�INA`T1L tJ ct�'T <br /> coMMENrs: �Yw� RECEIVED <br /> MAY 17 2011 <br /> qav <br /> �ENVOIRONIME T <br /> t{EALTH DEPAR <br /> ACCEPTED BY: /�(,,J�i EMPLOYEE#: 9o-01 DATE: <br /> ASSIGNED TO: A6 O Ok hs EMPLOYEE#: 'S— DATE: <br /> Date Service Completed (it already completed): SERVICE CODE: 3�� PIE: .1 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice # Check# r eceive By: <br /> EHD 48-02-025 SR FORM(Golden Roo) <br /> REVISED 11/17/2003 <br />