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SAN JOAQUI.OUNTY ENVIRONMENTAL HEALTH _ ,.;PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />5IQON I Gg. <br />OWNER / OPERATOR r <br />S ‘RQ,,\.)e_ CHECK if <br />f -c BILLING ADDRESS <br />-Y-c-'_C) <br />FACILITY NAME <br />,Nc H A Y \D c S fir I I?) Y (a S- <br />SITE ADDRESS <br />i'l(; T31 5 5-Q-cSVeelt i N um ber Direction I <br />S, C.X Ct fl'IC' il4 1 /4D <br />Street Name <br />t o ), <br />City <br />9 5 a L( 0 <br />Zip Code <br />HOME Of MAILING ADDRESS qf .Differept from Site Address) <br />LI 5 0 0 1,-/ II \iv Y 9 9 5 ‘ * --"? /Street Number C Ck Street Name Cr <br />CITY , STATE ZIP 5 to c kNo (\ C ck 9 52 I <br />PHONE #1 #1 EXT. <br />( .1,.,; 9) dit .578 --Litt -8 ci <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />SOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />- — t Si), ,S R,67I'Velf0 CHECK if BILLING ADDRESS <br />d. BUSINESS NAME e_ IIII (Li) --ra <br />V4),S._i, <br />li PHONE # <br />(02(1) <br />EXT. <br />HOME or MAILING ADDRESS <br />\-1 9 0 0 N ii \-ki NI q cri s ? A-* 5 9 FAX # <br />( ) <br />Crry -A K \ _-; c 0 Cc STATE c 0,.. ZIP qcj.....i ,?... <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 and FEDE1 2, laws. 1 <br />If APPLICANT is not 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 <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 sameArne it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Ntckq ->biri CA0 Ibt I tritiP6 ii-ttki.-:1 <br />'il• <br />COMMENTS: <br /> <br />skv./0,4 4 ,4,41„„chit,„ <br />ttii7i l< p <br />4k-4 <br />ACCEPTED BY: La(A,C0 'S <br />EMPLOYEE #: qp DATE: <br />ASSIGNED TO: <br />iVa‘r 1 C I <br />EMPLOYEE #: DATE: i ' //Ay <br />Date Service Completed (if already completed): SERVICE CODE: 6(1 P / E: / /(76 .-. <br />Fee Amount: 4 1 5 ),.. do Amount Pahip / ;----) Payment Date <br />Payment Type Invoice # Check # Received By: <br />/ <br />APPLICANT'S SIGNATURE: X2-4h-.}-7 * DATE: <br />PROPERTY/BUSINESS OWNERO ERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)