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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/ M ey/6(wo di-urri55 , r?elleilLs <br />FACILITY ID # SERVICE REQUEST # <br />OWNER I OPERATOR <br />To .61f1.icirtIO <br />CHECK if BILLING ADDRESS <br />FACILITY NAME F I <br />i /4 ZI- WO cl(vid-oc CF If ei 1 cg <br />SITE ADDRESS <br />5---° g Street Number Direction 7 ( <br />/ / 'fr, Street Name 114 0 d ewS/'0Cl/ ci Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />*7;1 Pi rigd a (?• Dr- Street Number Street Name <br />Cm' 1 , STAI ZIP <br />PHONE #1 EXT. <br />y) -7a, 9 3 77 <br />APN# LAND USE APPLICATION # <br />Pii6NE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />RE STOR <br />0 4 eV Cci I C I o i 0 CHECK <br />, <br />if BILLING ADDRESS )2 <br />USINESS NAME / <br />()(-) r(ri 4 0 <br />t r <br />01 LI (OS iec( let7cC , <br />PuoNE# <br />Po') -11-• <br />EXT. <br />6 ) ---2 ---) <br />HOME Or MAILING:XDRESS Fax # <br />/ CITY ,- STATE C-/-` , <br />/ <br />i <br /> , <br />ZIP 95-2. if /1 <br />.t7c- <br />BELLING 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, ST E a FEDERAL laws <br />OWNER OPERATOR/MANAGER El OTHER AUTHORIZED AGENT El <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br />my representative. <br />APPLICANT'S SIGNATURE: <br />zz <br />PROPERTY/BUSINESS <br />Cr- DATE: 7A 3 /‘. <br />x , \ PAYNItt TYPE OF SERVICE REQUESTED: -(f7oc e-VI I c- -c- i RECOVI COMMENTS: <br />JUL- 2 8 2 <br />SAN JOAQUIN C <br />ENVIROMEh <br />HEALTH DEPAR <br />ACCEPTED BY: C--CA EMPLOYEE #: DATE: 7 c.25., ) k <br />ASSIGNED TO: v A V ND )-02,4) EMPLOYEE #: DATE: -7 _ cws )(_, <br />Date Service Completed (if already completed): SERVICE CODE: <br />Fee Amount:\--.C.)-------- Amount Paid , Payment Date --? /-• 57 f/6 <br />Received By:2C -4 Payment Type c ci h Invoice # Check # <br />ED <br />16 <br />OUNTY <br />TAL <br />WENT <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08