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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST A p 5 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fA 001 Y1 I ('0:E12 oDL2M---i'V <br /> OWNER/OPERATOR 5ANID A POpr.Es <br /> /"l 'J CHECK if BILLING ADDRE55E] <br /> FACILrrY NAME e MI A A /l.�a-(---b9 t �j ��,,� ( <br /> SITE ADDRESS I3� !"IL1ct 1�V�a.�.� 1 ,2✓l l !/I nil ATL-tit otsw-2 <br /> StreetNumber I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS 1(if Different from Site Add <br /> ress) <br /> lV / �LLE Ir t/�L • Street Number Street Name <br /> CITY SIV I OIV STATE 6A, Zip q 52-19 <br /> PHONE#t ^ Erzr• APN# LAND USE APPLICATION# <br /> (Zc)c1 qo5 12— (o9 <br /> PHONE#2 Ear. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 5 fr-tsID yl A n O B <br /> rv"� '�iJ CHECK if BILLING ADDRESS <br /> BUSINESS NAME IMONE# <br /> Ml HA7-Alt- N y �f05 1 - 69 R. <br /> HOME Or MAILING ADDRESS1D95Z �L-E6NEWN 19L . FAx# <br /> ( ) <br /> CITY STZ')i ✓-1DQ STATE ZIP 52 <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: C:!5,0(tzrct �A DATE: i L Z 3 1;-02- 0 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El ~ <br /> IfAPPLICANr is not the BILL12VG 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. (( ,, p <br /> TYPE OF SERVICE REQUESTED: � w h I cu <br /> COMMENTS: <br /> vtlt Jt1 3 <br /> �R9p�tN <br /> ��O�MF�Nry <br /> ACCEPTED BY: y rn&IOd/j o EMPLOYEE#: DATE: IZ u')) 'L(] <br /> ASSIGNED TO: I Y l .F EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: `�L� Amount Paid !S� b Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />