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SAN JOAQUIN rOLINTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />C1 e ,-) .1 1 <br />OWNER / OPERATOV <br />FACILITY ID # <br />5R <br /> <br />-00 5 9 i I 8 <br />SERVICE REQUEST # <br />CHECK if <br />,3at who <br />BILLING ADDRESS <br />NAME FACILITY NAME <br />-1--VIt o' t,,2 _ <br />SITE ADDRVSS,‘ cc <br />---izi 0. lAilfr 4:telt-Number Direction Street Name <br />/66 ga4165 <br />City <br />q_36,)j <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />7 0 5— P t '6, f(li C CAI (k- 17Z— A k)- Street Number Street Name <br />CITY (S)TATE ZIP k us 0 CeAl 0 cik- ci* ,36, 3 <br />PHONE #1#1 EXT. <br />oc y y 24 — 0 / i ( <br />APN if <br />,-.€----- <br />I LAND USE APPLICATION # <br />PHONE #2 EXT. <br />oce-7) ,--3--- s-v- — <br />BOS DISTRICT <br />II <br />LOCATpr <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE 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 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, Standard STATE and FEDERAL laws. <br />a/427,Q_ DATE: //// <br />AUTHORIZATION TO RELEASE INFORMATION: 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 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. <br />TYPE OF SERVICE REQUESTED: y-- 00_6 ki_-•i-(c c..L_c____ Co Ai s Lt_ LTh-7-1-6 '‘-) <br />COMMENTS: Vfki— 0 <br />VAECeN\ N lot <br />SP <br />GOL)Yr <br />s 30 PCI`S/4104,17b0 <br />ACCEPTED BY: 0 (--- I kiE t 1.2-44- <br />EMPLOYEE #: 0 24 DATE: i /ii // 0 <br />ASSIGNED TO: \[0.4t_tto‘i EMPLOYEE #: / 6 ? DATE: I 1(1 /10 <br />Date Service Completed (if already completed): SERVICE CODE: D6, 1 PIE: <br />Fee Amount: 4 I t- C.- 0-D Amount Paid Payment Date \._ l ‘,4-/ \ b <br />Payment Type c_dki, Invoice # Check # Received By: vrc, <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGEVO OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003