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a - , <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type Of Business or Property FACILITY ID SERVICE REQUEST# <br /> # <br /> S'/L 00 (2-062_ <br /> OWNER 1 OPERATOR CHECK If BILLING ADDRi:SS <br /> ! G VA AZpa LL <br /> FACILITY NAME <br /> SITEADoaEs ( 'Zt y� >�/a¢� a.4,� .�c.'4Gbr+/ g30 <br /> I !� �z/� � Street Number 0 ectlon Street Name city2I Gade <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name /�r <br /> CITYIAV /�. STATE A i1� ZIP 6 �/ <br /> P++aNE#t ExT• APN# LAND USEEEAAP�PUCATION# <br /> z7�Z z3-Z7b�blo 07 a9 - 11 /t45_) <br /> 1 <br /> PHONE#Z EKT• -- SOS DISTRICT LOCATION CODE <br /> { <br /> CONTRACTOR! SERVICE REQUESTOR <br /> REQUESTOR � r� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE <br /> 3✓ J� � ��O �r7 <br /> ZZ AVIAIx v.¢ <br /> HOME or maluw ADDRESS FAx# <br /> CITY $TATE�� ZIP <br /> BILI:i11>'G 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 /> COUNTX Ordinance Codes,Standards,STATE a EDERAL laws. <br /> Z� <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER© OPERATOR/MANAGER OTHER AUTHORizEDAGE <br /> If APPLICANT is not the BILLING PARTY PrR authorization to sign Its requireed tit t e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 env ironmental/sRe.asstssmerat . <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time if is <br /> provided to me or my representative. 5/ ��pp <br /> TYPE OF SERVICEREQUESTED: <br /> COMMENTS: L �a PAYwENT <br /> j11S- RECEIVED <br /> upal <br /> i �' MAR 0 4 2011 <br /> SAN JOAQUIN CCI!.!?; _ <br /> - ENVIROldMENT,=h; <br /> ACCEPTED EMPLOYEE#: 0 j DATE: 3 <br /> DEP <br /> ASSIGNED TO: �lO� L{.L <br /> t2Zq1 EMPLOYEE#: LFbtFLS-- DATE: 314-let <br /> Date Service Completed (if already completed): SERVICE CODE: 3 f.S PIF: 2.-(003 <br /> Fee Amount: �C, Amount Pald Payment Date 3 CT <br /> Payment TypeGf{ r invoice# Check# 2013 7 Received By: t <br /> EHD 48-02-025 SR FORK{(Golden Rod) <br /> REVISED 11/1712003 <br /> r. <br />