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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />FACILITY ID # Stilvlut REQUEST # <br />tW <br />5(z_ oc) loD-te <br />CHECK if BILLING ADDRESS <br />Type of Business or Property <br />Von ia)0( <br />OWNER / OPERATOR <br />muCkME c)5\101-\ <br />FaciLiry NAME <br />SITE ADDRESS 1_,7 . q5s2.42 <br />Street Number Direction Street Name Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) WOOn 'OM 01 <br />Street Name <br />CITY <br />SIAN do5-E <br /> <br />PHONE #1 EXT. <br /> <br />q6i) -- L\ 8 11 <br />PHONE #2 <br />I 1 <br />I1_()\ NW tiAlEg,'S <br />0 0 Street Number <br />EXT. <br />APN # <br />STATE <br />LAND USE APPLICATION # <br />ZIP <br />LOCATION CODE <br />96RG <br />CONTRACTOR / SERVICE REQUESTOR <br />(fik)R ME 3 S IMO <br />BUSINESS NAME_ (sk 1ER )N s E H <br />IITCZLING A°7-Isf, wc,005 <br />(\l1 <br />CITY coA IQ Jo S E <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 Eiwi ZONMENTAL 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 SIGNATU <br />PROPERTY! BUSINESS OWNERIR <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 o; 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 />pl uv IUGU Ill Ili, v. lily 1 ,..,Fa ...,,,•.L,." • ._,• <br />TYPE OF SERVICE REQUESTED: C0115 LAI -1--cc,--1 on DAN. f Nil' <br />COMMENTS: <br />) <br />SAN <br />- A <br />BEcEivED <br />NoV <br />ENvIRomENTAL <br />1F) 2_016 <br />JOP COUNT/ OWN _ <br />—-4 DEPAFfTTAN f 7r1 ,-- <br />DATE: 1 / __, )1 <br />ACCEPTED BY: ---6, EMPLOYEE #: <br />EMPLOYEE #: DATE: / 1 .... / X _ 1 4, <br />ASSIGNED TO: 0 SS /(v) <br />Date Service Completed (if already completed): SERVICE CODE: 0 / P / E: //g o ca <br />Fee Amount: 1 ---, — Amc ur t Paid i 3 ci _ Payment Date I ( ___. u cg— ( <br />Invoice # Payment Type(ct ,/..._\ I Check # Received By: <br />REQUESTOR <br />STATE <br /> rPHONE # <br />FAX # <br />) <br />ZIP Ci136 <br />CHECK if BILLING ADDRESS.2(f- <br />0 DATE:)/—/ <br />OPERATOR / MANAGER -Ea OTHER AUTHORIZED AGENT 0 <br />Title <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (GoRod)