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SAN JOAQUL . .OUNTY ENVIRONMENTAL HEALTL SPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />;;;; 1111 ^ <br />BUSINE33 NAME No Y'Q I/1 LO ) /' <br />I I POE) u� <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER/OPERATOR /` //�' <br />,1 / /�1 <br />In tJV,�II 11G.62r ��v <br />' If BILLING <br />� _�.,,T, r��.{-yam <br />/ �CH/E'�CK <br />FACILITY NAME t / I Crt U' lC( //1��/, I I � %ADDRESS <br />YI (E Vv I 1 +J OC I V / — \J • / <br />SITE ADDRESS IYt L 2 7 <br />Street Number <br />.� // <br />IDIIRou <br />, n RJ � r/ �,,� 9`2 ©-2 <br />swat <br />J ' Sitreat Name (' it, 1J 1 ncCode <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />t L� <br />Stme Number <br />(7 ( E) d o ro d Q � ] <br />) U l Street Nae <br />1 ' JJ�� <br />CITY S.t_oc I 'LJ�) <br />''�v <br />p� /(-�/ <br />/-� i$TATE f ✓ Q` v t <br />l_f-/LAND <br />PHONE#111 <br />�• <br />ony) 952 -C?D(D <br />APN # <br />USE APPLICAnO`N # <br />PHONEY EXT. <br />I Invoice# <br />SOS DISTRICT <br />LDcanDx CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />CHECK If BILLING ADDRESS IS <br />REQUESTOR Pbmllorl P001!5 — r I ) of r- F 1 r-V<1e <br />;;;; 1111 ^ <br />BUSINE33 NAME No Y'Q I/1 LO ) /' <br />I I POE) u� <br />PHONE 3 rj / q r , i a� 33 <br />HON�r; _7 <br />) in � <br />F ) �L.l � <br />1((D..R��ES. <br />CITY Loa <br />STAT09 LP c5gvo <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, Stand , STA d FEDERAL laws. c <br />APPLICANT'S SIGNATURE: DATE: 2 c� /��'�J f y/ <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MAN. R ❑ OTHER AUTHORIZED ACENT�o <br />IfAPPLiCANT is not theBYLttlycPAxr't' 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 ENVmoNMI-:NTAL 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: -pre — P l asiff r ( c <br />fc,hon <br />(B -t r ' voo <br />COMMENTS: C.o ✓1S t.L.` 1 v. O✓1 <br />PAYMF <br />RE��IV <br />Jut <br />HF4�RpA�COa <br />ACCEPTED BY:1� <br />1��,^ <br />EMPLOYEE#: <br />ASSIGNED TO: pes <br />EMPLOYEE#: <br />DATE: -7,aa_/� <br />Date Service Completed (N already completed): <br />SERVICECODE: (-J-"�� <br />PI I-3 <br />Fee Amount:�j <br />Amount Pal 0 <br />Payment Date 7 S <br />Payment Type Vlb�f <br />I Invoice# <br />Ch k# Q <br />, 033630 <br />I Received By. <br />EHD 48-02-025 F �� 1 V + SR FORM (Golden Rod) <br />REVISED 11/17/2003 �f�j' ; Y� <br />J liv 1 [t <br />f5 <br />