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SAN JOAQUIN QOUNTY ENVIRONMENTAL HEALTEPARTMENT <br />SERVICE REQUEST V <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESS NAMEG�.{.2�e-L <br />✓✓ `` <br />ERVICE REQUEST # <br />Ga�l;ne pts�an5i+,� �"-,�ciJi+ <br />SAENVI�pEPp�T <br />FAX # <br />(747 ) 74-5 <br />CITY Goal uftA2 <br />OWNER / OPERATOR <br />if <br />BILLING ADDRESS ❑ <br />AG, `' 1 Oilf2r,o�i JGl*' 1 1 G� <br />1 lJ <br />Irs <br />SERVICE CODE: i 9 k <br />CHECK <br />Fee Amount: 41 1 5u? <br />FACILITY NAME <br />�hlall 'JCoI S� Tri 5ke ll <br />1. Min; tl2r+ <br />" L 11 <br />Payment Type t s -T <br />SITE ADDRESS <br />ES <br />Check # f ?15 <br />Received By: <br />Id Tracy <br />—T <br />a5�%�O <br />72 ✓ Street Number <br />Direction <br />Street Name <br />CI <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />c ) <br />APN # <br />2;/2- J7c t3() <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />( ) <br />Z- <br />3 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />042 e 2ni tnfl <br />CHECK if BILLING ADDRESS Er <br />BUSINESS NAMEG�.{.2�e-L <br />✓✓ `` <br />P EGE vED <br />10 2p09 <br />MPR <br />GO VNO <br />PHONE# ExT. <br />707 &5.1G60 1Dw <br />HOME or MAILING ADDRESS 137 � 1 - M. T"). dll IZ�d - <br />IV W�W� (f <br />SAENVI�pEPp�T <br />FAX # <br />(747 ) 74-5 <br />CITY Goal uftA2 <br />STATE 6 ZIP 9+154 <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE:%� L"~ Oh 6elie d Able I ►21r7>ara z.-- DATE: .5 J5 ,� <br />PROPERTY/ BUSINESS OWNER❑ -Ly-/OPERATOR/ MANAGER 11 OTHER AUTHORIZED AGENT Y �t� -5'rt 1& M2i-At. <br />If APPtlCANT is not the B/LL/NG 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 />TYPE OF SERVICE REQUESTED: Lk S T u F i t <br />�J ( 7--;C-7 fJ 10 c <br />COMMENTS: <br />RUSH <br />P EGE vED <br />10 2p09 <br />MPR <br />GO VNO <br />RUSH <br />ACCEPTED BY: 0 C_ t ,.j E I lL <br />SAENVI�pEPp�T <br />I LOYEE #: 2] Z _t <br />DATE: j <br />ASSIGNED TO: <br />EMPLOYEE M �(r, C/ 2 <br />DATE: 3 /10/0,9 <br />Date Service Completed (i already completed): <br />SERVICE CODE: i 9 k <br />P / E: Z3 C, k <br />Fee Amount: 41 1 5u? <br />Amount Paid f4q-7 -, jD <br />Payment Date 3 D 0 <br />Payment Type t s -T <br />Invoice # <br />Check # f ?15 <br />Received By: <br />EHD 48-02-025 / / d 7 ($/d7•sj\� SR FORM (Golden Rod) <br />REVISED 11/17/2003 /907 61V ST '/ <br />