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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ge-5/14441for. / <br />FACILITY ID # <br />— <br />ttY j C-,1-i /,_ <br />SERVICE REQUEST # <br /> <br />- . , ( <br /> <br />,-7 <br />• / i <br />OWNER/ OPERATOR 1 CHECK if <br />be e, MaG.A/4/ <br /> BILLING ADDRESS <br />FACILITY NAME NAME r- <br />rerwrze-v- 'cl‘,7 .1/4:34____ ,ParA9,1 <br />SITE ADDRESS <br />/t2eete Street Number Direction <br />2,00,10.-4,4140c, X -S i,4,d Sit5C--- <br />V Street Name <br />--.1.10 in <br />City <br />95ZI5 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Err. <br />(ZO 1 ) WO - 7& 35 <br />APN # I LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT <br />II <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR jora4vi <br />Ze,ar/ 'S CHECK if BILLING ADDRESS 0 <br />BUSINESS NAME <br />-77,_ <br />PHONE <br />S e-le-e--r---- 6k-00 p <br /># Err. <br />(s- se) ) 27Z_ - c-izo 6 <br />HOME or MAILING ADDRESS <br />56 evu4A Vti% 5h-e4, 5' 2.06 <br />Fax # <br />(550 ) 272_ - l-f2 / / <br />CITY 6frar 6 5 149 &Ai STATE ZIP (4_ <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, STA nd <br />1 <br />FED L laws. <br />— <br />Or - <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 <br />DATE: <br />OTHER AUTHORIZED AGENT El ,1.4/17. y- %KZ' 6ep <br />APPLICANT'S SIGNATURE: <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 RE Q U E ST ED:/.11r_ M - r, 0e, 7/ & 4,7'. 4-144/ .71 lig,d/Grik7L/dn <br />("1741/° COMMENTS: <br />1 <br />ACCEPTED BY: <br />I/7i'vkf Ih / <br />EMPLOYEE #: <br />„ <br />DATE: 5/t/ .7 <br />f ASSIGNED TO: EMPLOYEE #: DATE: 3 // <br />f ' <br />Date Service Completed (if already completed): SERVICE CODE: P/ : <br />Fee Amount: ' Amount Paid - <br />i <br />Payment Date <br />Payment Type Invoice # Check # Received By: <br />END 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003