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SAN JOAQUI WUNTY ENVIRONMENTAL HEALTOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK if BILLING ADDRESS <br />SERVICE REQUEST # <br />Gct!s1017 <br />PHONE # <br />aDl <br />ate -X0„5.3533 <br />OWNER / OPEF70R <br />//� CHECK if BILLING ADDRESS <br />60 <br />0 CIO <br />FAX # <br />FACILITY NAME& �� '1 ! <br />hcco / Z,�& S `/ � <br />a <br />SITE ADDRESS Sana <br />Q <br />14�n <br />0.Vvt m e f' <br />CITY 6 cK f _ <br />S4 a�-k �+ <br />q <br />Street Number <br />Direction i <br />treet Name <br />ASSIGNED TO: <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />DATE: 3 1510'? <br />los h .tea <br />t ` Street Number <br />r <br />Street Name <br />CITY <br />vk'k-Sdna-tm <br />STATE ZIP <br />-7-1< d79 <br />PHONE #1 ExT. <br />( � 5 r7-1700 s,Vit. <br />APN # <br />002 -32tJ —1 <br />LAND USE APPLICATION # <br />PHONE#2 ExT. <br />�.�J� asp - 9vos Kent �p � o � rvta.�►- <br />BOS DISTRICT <br />�- <br />LOCATION CODE <br />/ <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />e_ 1. v� <br />PP %V l diFv <br />CHECK if BILLING ADDRESS <br />BUSINESS N _ <br />E "V e- , Yc�G�-rr/' 4 n� <br />PHONE # <br />aDl <br />ExT. <br />L/4,1- 63 3 <br />HOME or MAILING ADDRESS <br />a-53,5- (,cit <br />r <br />FAX # <br />(/ <br />VL Co3 a <br />a <br />(Xl <br />T <br />CITY 6 cK f _ <br />STATE C Q <br />ZIP 01 <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, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURES_ �� DATE: - S v S <br />�-o <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT V 4'C- le CO O r rt-koy- <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 same time it is <br />provided to me or my representative. <br />,t, nFN _- <br />TYPE OF SERVICE REQUESTED: -r 4-e- T-4-0 F- f T <br />PP %V l diFv <br />COMMENTS: <br />GOON TY <br />JOAQVIN <br />SAN ONMENT ENT <br />H <br />DEPARTM <br />NEp� <br />ACCEPTED BY:t <br />/ ,D <br />K <br />EMPLOYEE #: <br />DATE: '3 <br />ASSIGNED TO: <br />�1 C-kf�� <br />EMPLOYEE #: �-2, b <br />DATE: 3 1510'? <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />l �i <br />P 1 E: 9_3 pk <br />Fee Amount: <br />Zct <br />Amount Paid a 4_60 <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # � LVn <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />