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SAN JOAQACOUNTY ENVIRONMENTAL HEALAEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />SERVICE REQUEST # <br />CHECK if BILLING ADDRESS <br />BUSINESS NAMEE <br />Ste'✓ y t'wo-s�rz�v <br />OWNER / OPERATOR _ _ <br />LA/ _ / � r`D �, CHECK If BILLING ADDRESS <br />G�LU� Vc� lG�/� <br />FACILITY NAMEeaelq/ �F/GL <br />SITE ADDRESS <br />I <br />S. <br />j,eiq-zf <br />%% <br />3// 30 Street Number <br />Directlo <br />Street Name <br />C <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Received By: <br />0 %� / �` Street Number <br />Street Name <br />CITY �r �x / d ^� STATE �W ZIP <br />•7 <br />PHONE #f EXT. <br />L209) �f 6�-.�vZ 6 <br />APN # <br />a ss -02 o --i <br />LAND USE APPLICATION # <br />PHONE ) 7 a E-. <br />BOS DISTRICT _ <br />LOCATI-© E <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />COMMENTS:,tD `�,I� L //✓C�/���� -. p �' /yt��' 'lop uy✓ ,✓fi'1j�e <br />07=7 3 <br />roo= y �v v�:.y !r�-.r ^14ers� <br />J;r v -' is ��.�a jam✓ % lw s-. .��c, i!�/� /.✓� S �✓/cam �� .c� <br />CHECK if BILLING ADDRESS <br />BUSINESS NAMEE <br />Ste'✓ y t'wo-s�rz�v <br />PHONE # <br />EXT. <br />HOME Or MAILING ADDRESS �r D /S/O <br />O <br />F(� ) <br />p 74111"CITY <br />.�/r(�t' UT/ STATE <br />C� <br />ZIP / 5,�2,&7 <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 thS,3uqrk to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAAWi <br />APPLICANT'S SIGNATURE: 4j DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR / MANA R ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY. proof of authorization to sign is require <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: 4i ov,^1z 4I�ILL/i►/� <br />COMMENTS:,tD `�,I� L //✓C�/���� -. p �' /yt��' 'lop uy✓ ,✓fi'1j�e <br />07=7 3 <br />roo= y �v v�:.y !r�-.r ^14ers� <br />J;r v -' is ��.�a jam✓ % lw s-. .��c, i!�/� /.✓� S �✓/cam �� .c� <br />ACCEPTED BY:r <br />EMPLOYEE #: L%'�f ,g-� <br />DATE: Ya -0112- <br />ASSIGNEDTO: .lL-, <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: 3 X00 <br />PIE: L/VO 7 <br />Fee Amount:'1 ✓ <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />.t/��/i� - ���.G�r� s ae>► ' •- 3 A -f -t - AS -3 , S � <br />EHD 48-02-025 L�ZZi�2 - d6-l-�ls� W ''7R` ' `�` " I r/"`a°"�'`•'•�`�� ' SR FORM (Golden Rod) <br />REVISED 11/17/20032/Z3//2 - t�)6�ivc pS� b+-¢ 04W - 7111 <br />3 /1 A' -i <br />'rS <br />I . 3112- - 41W <br />,., <br />/y/1i 31/r//2 - �l c,�v•�,�,„ a -f .acW-/OA '2-a' <br />1✓� <br />