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SAN JOAQL —'OUNTY ENVIRONMENTAL HEALT, EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �a,SCLirJE Dtsa��ISIN� FAC1LIT 7� 3 '5;C&0 -- <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME c r t A t S C Q S A w l - ,t * /aq <br /> SITE ADDRESS "1 3--l� t W /�fLi tAC`f�{`- PI-C))F R l MA NA TSCA <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 601 (VAC }j'EM(�v/ A V'-E <br /> Street Number Street Name <br /> CITY „n .17� STATE (�yq^, ZIP <br /> g 5 3 S v <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (2m) 5`7`1 - 6occ) fg �- 2 �•--py <br /> PHONE#2 EXT. BOS DISTRICT __3 -] LOCATIO ODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 12U"flA NDN <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 130Yr T PETY`OG M <br /> rJZ7— X000 <br /> HOME or MAILING ADDRESS FAX# <br /> 6L-)I mc- +Ir-7NY1Y M E • (20-1) 57-7 - 604-0 <br /> CITY lA 0^FC yam., STATE CA ZIP <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 an E L laws. <br /> APPLICANT'S SIGNATURE: Y DATE: ID1&- 011 <br /> �/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ O ER AUTHORIZED AGENT��WS tT - SVq,, L CCVb' <br /> IfAPPLICA,VT is not the BILLIA�G RTI,proof of authorization to sign is required Title <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 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. y <br /> TYPE OF SERVICE REQUESTED: 1 �(,S\"� C- Cd S �'.C\C /1'9 %*Z�a1 ,/J .t A } �t NT <br /> COMMENTS: CO N s�✓TION OFIE ) vn 6'�"t-t MA U �1 I X OA tQAJ b IA REcE,v <br /> l� OQLA I /KA K I G CA S tTE 61 <br /> N <br /> SNS-SON� ONMEW E <br /> EN1 <br /> NNA pEPNR <br /> N�'TM <br /> ACCEPTED BY: U( l v`L EMPLOYEE#: �� DATE: t G ZU U <br /> ASSIGNED TO: LX EMPLOYEE#: (pZ G DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O Ce P I E: �3 <br /> Fee Amount: // i7'� Amount Paid ` C Payment Date 1� p <br /> Payment Type Invoice# Check# l S Received By: <br /> EHD 48-02-025 SR FORM(Golden <br /> REVISED 11/17/2003 / <br />