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SAN JOAQUIPOUNTY ENVIRONMENTAL HEALTH I NPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property f OF�I `l SERVICE REQUEST# <br /> > G.q�✓/'�/e <- 3 9, iC�.q -� S f-OU . 7 7� <br /> OWNER/OPERATOR _ D _ <br /> �/✓ ��/�y�u�/' eIOZ4//�-/—1, (,/8e�r �,/OW�f QE/p� j-&71 1 ARs?�ECK If BILLING ADDRESS <br /> FACILITY NAME�aRle�t Mn L0`_ l IrIN/%AOY �J <br /> SITE ADDRESS .fir/3 PUH eVxe,-?-e- �/"��u�✓ '-� �"'? y /-96 3?7 <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) lel o �:- 1 fjSL66 j a7V o-f f/E <br /> Street Number Street Name <br /> CITY j� STATE CfI ZIP q�2 O <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# / <br /> GW) //6r 3066 a 53 -o?o -lo <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) 4l 9 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME / u�nal^l e-024/147 <br /> �N7' ,CW�'Sdzl� P ONS 9 -.?,o er 4. . <br /> HOME Or MAILING ADDRESSc /0• Q ` J?�� F-u.9 4 J0 Y D 7-F <br /> CITY J /�(f—(�'�7'Q/%-/ STATE (rA ZIP 95.101 <br /> ✓ 2 0 / <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: A) a�; DATEy:� 2fl-111 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT JGr �Nw� �"`•'r Y��EE/� <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title EVE T <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner oroperator of the prope c ed at E6 <br /> above site address, hereby authorize the release of any and allresults, geotechnical data and/or enviro men aI/sit se7sft <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL.HEALTH DEPARTMENT as soon as it is available and ame time It is <br /> � <br /> provided to me or my representative. AQUIN C1FVF <br /> 11' <br /> TYPE OF SERVICE REQUESTED: // C--+ (2 c-) � <br /> rJ / G ,-1c 743D � <br /> COMMENTS:PRIt 11-1V7 PCe-W// l�W //V1Ti9L l/N< 3 'Ve O �/'PY✓A�/L L <br /> ��s ��TiQR L'%��1�✓ ti•��c S �E'er o�r� E�Z � �E.Q-.e i�c <br /> /!/OAC/'/�!Z/'/ P.PO�FJe%� .8d�1n�Af�re'� D� %hiE G•9�✓DG/�G . <br /> A'� <br /> ACCEPTED BY: i In EMPLOYEE#: / DATE: �Ln l27 G p <br /> ASSIGNED TO: J L( 1,1.,-'1 OT A.)I v 4 EMPLOYEE#: L�6 9-u DATE: / 12-7 l0 <br /> Date Service Completed (if already completed): SERVICE CODE: :�c3 PIE: Li4c)-7 <br /> Fee Amount: 3 i S• uZ Amount Paid S� Payment Date tb 21 p <br /> Payment Type S S- , Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 _ AS <br /> 12/.d 1 t�g -_ �-�r�.os ef� ,e�-'�c. ��y-f�-ua�-�� - 2_S`d.<Y' •`S <br />