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SAN JOAQ UOUNTY ENVIRONMENTAL HEALTH*ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s(ZOE) 0sz(-) I <br /> OWNER i OPERATOR /� <br /> paca 4 c 13--d TeP h e Co. v l 6a r` ' 9-T ca I;�l� CHECK If BILLING ADDRESS <br /> FACILITY NAME A Tq--r /r '-IFoS <br /> �^A <br /> SITEADDIjES3 � ���re I,�n S Isbck- <br /> - <br /> 9'5�z <br /> 3 Street Number Direction Street Name Ci Zi Code <br /> Ho MAILING ADDRESS (If Different from Site Address)'�/�/� ��;qO Q�,,.,,,,A <br /> (fix) Can�lno R2krno+rl ' 1��� �"'QtreetNumber r�Strre'ettcNJa'm'ee <br /> CITY � � QE 4450 <br /> PHONE#t ExT• APN# LAND USE APPLICATION# <br /> (214 ) 4104-5511 129 - 40 -0( <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> " CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR C'k <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME Sty�e- r, ,„,L ' (�G PHONE 4/S - 16`O E>R' <br /> HOME or A/g j <br /> r, Mo(�a( ��� 465-9q0? <br /> CITY P�1,., l,.rw�Q <br /> STATE ZIP G�4g5+ <br /> BILLI`NC,GI�t`VIr 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 applica Ion ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STARn ED laws. ^7 <br /> !xAAPPLICANT'S SIGNATURE: DATE: rxo T2/y2�^f L- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER O OTHER AUTHORIZED AGENT Ia N"eGt- 1''dt /S <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 14 Titte <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: pAYME <br /> COMMENTS: <br /> SUN 2 7 2012 <br /> SAN JOAQUIN COUNTY <br /> HEALN DEPARTMENT <br /> ACCEPTED BY: ` EMPLOYEE#:(��`,; DATE: <br /> ASSIGNED TO: EMPLOYEE#: l C DATE: <br /> Date Service Completed (if already mpleted): SERVICE CODE: 1 P I It.,Z3ae <br /> Fee Amount: 3 S Amount Paid �3? Q Payment Date 2-7 -z— <br /> Payment Type Invoice# Check# ©�b Received By: <br /> EHD 48-02-025 �� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />