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SAN JOAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />rrnDbi ie furl -fro/ 1 ei <br />FACILITY ID # SERVICE REQUEST # <br />Ja <br />OWNER! OPERATOR , D , , . . <br />an/ et wil/jum S <br />CHECK if BILLING ADDRESS/a' <br />FACILITY NAME"--- <br />/ OS ike liox as <br />SITE ADDRESS <br />Street Number Direction Street Name City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) q..E5 0 5 <br />Street Number Dn ver Pci. Street Name <br />CITY • i <br />VOI.Pq S pnnqs STATE os„ Zip <br />9 "52 GO__i <br />PHONE #1 EXT. <br />( (OSD /53 ' -I - 24'o3 <br />APN# LAND USE APPLICATION # <br />PC),NE #2 EXT. <br />('L1) CH (0 .-- ()g (00 <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Oan; el OM ()tins CHECK if BILLING ADDRESS E" <br />BUSINESS NAME Ta1/43k, of -rgy Qs, PHONE # <br />((O50 7 -2LY?S <br />EXT. <br />.g <br />HOME Or MAiLiNG ADDRESS tit %5 Driver p L <br />_ <br />i <br />1 <br />. <br />FAX # <br />( ) <br />CITY VO ii 0 cDr- 1 nos STATE Cf---- ZIP qs 2s-2 <br />BILLING ACKN LE GEME T: 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, STATE and FEDERAL laws. <br />*.APPLICANT'S SIGNATURE: 11:k- lid <br /> <br />DATE: -4 / 7 ; , <br />PROPERTY! BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 pro81 me Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: V•Pet,k. ok 4 ex I... <br />COMMENTS: 17: , N , --\-r.,ilqf <br />Stp .,, , <br />4 1 2 '- sAN j, Ott <br />ivt%/1"9 Q 4-lliki c fitA ROA/44 OUtvp I. TN D, E-Airil , <br />,--.HARrmE`A/7 <br />ACCEPTED BY:,fA4e,744ket. EMPLOYEE #: DATE: at _1 iv <br />ASSIGNED TO: F-1 ,i, ,LA ,„÷Z., EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: C' .1-5 PIE: <br />Fee Amount: <br />1) Li S.4. 00 , <br />Amount Paid, 1-7/57,-,, 67" Payment Date 7/7 <br />Payment Type e_ Invoice # Check # Received By://:( <br />Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08