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APPLICANT'S SIGNATURE:
<br />PROPERTY/ BUSINESS OWNERS OPERAT
<br />DATE:
<br />R / MANAGER 0 OTHER AUTHORIZED AGENT 0
<br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST
<br />............, ..,.....
<br />' Property IIRED. FACILITY ID # SERVICE REQUEST #
<br />S 700'i 7S--1)5
<br />OWNER/OPERATOR .
<br />,/6-..5' CHECK if /000 t1,4--1-$0 ,J c- 11 icy-c2.. : 444 - BILLING ADDRESS 14
<br />FACILITY NAME
<br />SITE ADDRESS
<br />'2.-C.-,-1 Street Number
<br />—
<br />L._
<br />Direction
<br />jA H-A-N..; -,--- 2i-.
<br />Street Name
<br />,, A eA-t-IPO
<br />'-.,.--,---,e.r.,-,-4 -',_5".2 v 2
<br />Zip Code City
<br />HOME or MAILING ADDRESS (If Different from Site Address)
<br />Street Number Street Name
<br />CITY STATE ZIP
<br />PHONE #1 EXT.
<br />( '2_CK-j ) 42. • Li 73 I
<br />APN #
<br />OC)Li.c.95 03.0
<br />LAND USE APPLICATION #
<br />PHONE #2 EXT.
<br />(910) s-71 -062 4
<br />BOS DISTRICT 1.1 LOCATION CODE ,
<br />9 ual
<br />CONTRACTOR / SERVICE RE UESTOR
<br />REQUESTOR 1
<br />41-S0/- Z /7/0-1-ELL_ -0- 2444-/CS CHECK if BILLING ADDRESS
<br />BUSINESS NAME PHONE # EXT.
<br />(2b'-)) q 23 -
<br />626-7 6.
<br />HOME or MAILING ADDRESS FAX/it J /41-1---A,J ,---
<br />CITY 4 6.4./....vo STATE 6,4 ZIP
<br />
<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 EDERAL law'.)
<br />CALL (209) 953-7697
<br />FOR INSPECTION.
<br />48 H
<br />REQ
<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
<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.
<br />TYPE OF SERVICE REQUESTED: Ver lc)/ locej-14-1 of s (-12)-ie. tc, vi le ei yg:',/ n o r iii ivp..5i jet.; di
<br />COMMENTS: R o p,...6,v161 h q(7/0 c 1,-.0) 61' the n.rtk p.rh)e, A:if hc,-,sf 01,(/ fop, t sli.ws it i 0 ))')/e
<br />cilee'• t)0"'1 a } cio.cintt 4 mrtkrAlrg-knof.t le.701 Ole ).-0 6c ,,,,(jo I-ph to .1, e it, c/ti,
<br />ctl 0 6,-- pielco."), t):),, ,v) e n 1 cii 51..6-.1 0( e 0C gesPh, Mrde 10 60 :7 (A i or, 4.0-Cr • g'''
<br />‘f sti,ci-u/e.
<br />3 SAN • 4
<br />ACCEPTED BY:, ..-77.--._ .,;:7- Z., ,(2.---- EMPLOYEE #:Ci(J/N DATE:
<br />ASSIGNED TO: F rz. EMPLOYEE #: DATE: y <- ?"Polfiir44"1
<br />Date Service Completed (if already completed): SERVICE CODE: 0C..1) I
<br />Payment Date
<br />Received
<br />)4191)4
<br />PIE: Lido3
<br />By:1
<br />Fee Amount: 4:) 5-02 Amount Paid
<br />(S' o------
<br />Payment Type (1 ,3100,0 „) Invoice # TIM 2 ')-co (Q Y)
<br />V
<br />EHD 48-02-025
<br />SR FORM (Golden Rod)
<br />REVISED 11/17/2003
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