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L <br />• w SAN JOAO7IN COUNTY ENVIRONMENTAL HEALRDEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS" <br />FACILITY ID # <br />(' - <br />SERVICE REQUEST # <br />2�TA,[L ���� <br />I <br />m�V// <br />� oo51U-a <br />OWNER I OPERATOR <br />JUIq 2 w �l'IJ7 <br />U k V.. T Q P YR QV C �� r- <br />� 1 S <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />. 1, <br />j� �( &'r <br />A KVC E S A <br />F'7s-3 3 <br />5 o S Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />e <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />E �t,t V(Z P i L t <br />`/ <br />�+ S_ 6 IL <br />Street Number <br />ASSIGNED TO: <br />Street Name <br />CITY F (Z E (/� 0'.L T <br />STATE C^ Zip i/ 3 <br />7 <br />PHONE #1 Err. <br />DATE:, <br />APN # <br />LAND USE APPLICATION # <br />SS`oo <br />/GX CY <br />'2-17-ZC�O-Zl <br />Fee Amount: <br />��� c,� <br />PHONE #2T• <br />) <br />Payment Date (Z I ( o"7 <br />BOS DISTRICT <br />LOCATIQ CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR //j^ (^ /� C n -�� <br />CHECK if BILLING ADDRESS" <br />BUSINESS NAME f��i 2 i 1�L� <br />(' - <br />PHONE # Exr' <br />�-- <br />HOME Or MAILING ADDRESS <br />p.0, g©1c (Czs- <br />I <br />FAX# <br />(qr(v) -3 }3 -[(�-L <br />CITY t r 1, �� <br />STATE C X ZIP ? 51 1 3 6 <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 Pat the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STA d FE ERAL laws. <br />APPLICANT'S SIGNATURE• Im A I--- DATE: <br />01 - <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT C� C O tL A -C -4v n-- <br />If APPLICANT is not the BILLING PARTI: 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 environmentaUsite 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. I t ST 4 t -7— <br />TYPE <br />TYPE OF SERVICE REQUESTED: P C k4 <br />E V <br />COMMENTS: <br />IR EC E IV ED <br />JUIq 2 w �l'IJ7 <br />JUN 2 1 2007 <br />SAN JOAOUIN COUNTY <br />P�R11Ti("'I <br />ENVIRONMENTAL <br />ACCEPTED BY: <br />EMPLOYEE : ? Z-4 <br />DATE: / t / G % <br />ASSIGNED TO: <br />/UST /�t <br />EMPLOYEE M Z� "� C� <br />DATE:, <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />/GX CY <br />P 1 E:� U <br />Fee Amount: <br />��� c,� <br />Amount Paid <br />Payment Date (Z I ( o"7 <br />Payment Type <br />v ' <br />Invoice # <br />Check # (p <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />