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SAN JOAQUIN COUNTY ENV oNMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business_ or Property FACILITY ID# SERVICE REQUEST# <br /> gapA <br /> &Z:3� <br /> OWNER 1 OPERATOR rAfc(ZU K 8k-AN�-'E CHECK if BILUNo ADDRF$$0 <br /> FACILITY NAME N EN ti<'t f-1 l Gl-tT U DIG'S <br /> SrTE ADDRESS <br /> ,1 S' ZIR Code <br /> Ty Street Number Wrectron tre t "'@ C� <br /> fiOME of MAILING ADDRESS (if Different froth Site Address] 3 2 lmq �-�yN ft t��w K (Z. <br /> �p P-OL-ANI> GBNST?-'4c--001 1 street Number Str etlVame �• <br /> CITY S.� CC.�.Tt3 N STATE C-A ZIP Z Ol <br /> EXT, APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> (2o't1 �(a Z•- Z �O$2- Rtn�ttip 1��1- 1�''Z�3{Q +- -3�- PPt --1 000 E 3S <br /> PHoNe#2 Sa$ T KE $05 DISTRICT <br /> LOCATION CODE <br /> Z fo 1' <br /> CONTRACTOR/ SERVICE REQUESTOR. <br /> REQUESTOR S❑ <br /> E 1�1ALL CHECK IfBILLiNOADDRES <br /> PHONE# ' Exr, <br /> l3usINESSNAME uJE O+�K ( oEN�►1�-��W'�h��c L- - 2e1 lvy - o3�S' <br /> HOME or MAILING ADDRESS FAX# <br /> w ArleG �T- <br /> • a - . (moi} *09 ~ <br /> STATE C oN E ZIP s-j,,.fp <br /> CITY <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 ENVIRONMEN'T'AL 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 wor be performed will be done in accordance with all SAN JOAQUIN <br /> CoL TY Ordinance Codes,Standar , an FRAL S. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PRoI I BUSINESS OWNER TOR MANAGER ❑ OTtiFR AUTHORIZED AGENT <br /> If APPLICANT i the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZAT'IO TORELEASE I�`S�tlRl►'IATIflN: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 envirotunental/site assessment <br />`r information to the SAKI 30AQLIB3 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: !ZV lEW 501 SV l 1 l`�irj� _174 �N iTlr#�Tt LpAcOI N+G- STVDy <br /> COMMENTS: IZv� Sty /s, 25�j� REECEIVED <br /> APR 2 8 -2011 <br /> ism! .�G5c'eTrZo <br /> SAN JOAQUIN cc)UNTY <br /> EnIRON6rENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE.#: ©ATE: r��? <br /> Date Service Completed (if already completed): SERYICECODE. <br /> Fee Amount: Amount Paid � Payment Date <br /> Payment Type G,! invoice# Check# Received By: <br /> s SR FORM(Golden Rod) <br /> EHO 48-02-025 <br /> REVISED 11/17/2003 <br />