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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -FA,W201LI2 5`1400''l(O <br /> OWNER f OPERATOR ^ ///��� /�D / tO�J, /'t CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME LP Mo�2Es Sz3 l l../ V t <br /> SITE ADDRESS �2O C opt I A <br /> Stree[Nllumber Direction Street Name %1 L i" Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3 120 <br /> I ` <br /> WRIV1 34 LI 1 'D{ <br /> Street Number v• 41 ,NStre�et Name l <br /> CITY � M - STATE _ � <br /> ZIP 01 Ol <br /> PHONE#1 �J11/l",�lvr " Ems' APN# LAND USE^APPLICATION At <br /> (J q(OLI - q-7D <br /> —11 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> cw; V✓� �� CHECK If BILLING ADDRESS <br /> l�V 1. �/V EXT. <br /> BUSINESS NAME LA MO ne� JL /� PHONE# <br /> HOME Or MAILING ADDRESS I_t^_11G7 _ '}J' `7�^���,`� n f FAX ) <br /> CITY 4 17 -ly ( /� (� .�// V 1, STATE ZIP 41Cif D-1 <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 performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST E and F D L-J S. <br /> APPLICANT'S SIGNATURE: DATE: `� 1 <br /> PROPERTY I BUSINESS OWNER OPERA A R OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 of the BILLING PARTY,proof Of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address,hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is pd to me <br /> rovideAEW <br /> my representative. I 1 <br /> TYPE OF SERVICE REQUESTED: fop VEhtcju I VLS C,4fi---,\ RECEIVE <br /> COMMENTS: APR 12 rto <br /> SAN JOAQUIN Cot NTY <br /> ENVIRONMENT IL <br /> HEALTH DEPART ENT <br /> ACCEPTED BY: • M,R i.O tn.'J ==EMPLOYEE#: DATE: 4Z- ✓1 <br /> ASSIGNED TO: !�n EMPLOYEE#: DATE: Ll— <br /> . l•^I -1( <br /> Date Service Completed (if already completed): SERVICE CODE: OA/ 11:/ 0 <br /> Fee Amount: %2 Amount Paid 1 �L Payment Date v <br /> Payment Ty h oice# 0 0 y,O Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />