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SAN JOAQUIN "OUNTY ENVIRONMENTAL HEALT*EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />- // V E=E/f- '5tt v D , <br />FACILITY ID # <br />(7 <br />SERVICE REQUEST # <br />S )e0o <br />OWNER/ OPERATOR <br />CHECK if BILLING ADDRESS <br />FACILITY NAME ! <br />Pr- ),4L STvc\K'ro.v J��oBI �F sT,rt sn <br />SITE ADDRESS 8�Q0 <br />Street Number <br />�% <br />Direction <br />Vii -5 4# JE S7�`!���� <br />Street Name Cil <br />MAR 2 6 2010 <br />C <br />9J-/0 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />ACCEPTED BY: <br />,0 Ce vLC 19-4 <br />PHONE #1 <br />( ) <br />EXT' <br />APN # <br />0'(0 — 34C/-02, <br />LAND USE APPLICATION # <br />` <br />PHONE #2 <br />EXr. <br />BOS DISTRICT <br />LOCATIgN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />f/ (] Cn CHECK if BILLING ADDRESS <br />Za `JG `-F <br />BUSINESS NAME <br />- // V E=E/f- '5tt v D , <br />PHO # Ext <br />M) a /4 - e3 f <br />HOME or MAILING ADDRESS <br />FAx# <br />(56) a45' 6& f <br />CIN It it e /% STATE /7„ ZIP Q -33,1, <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 or <br />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 ill be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STAT al d ED L l s. <br />APPLICANT'S SIGNATURE: DATE: aj — "q 4 <br />PROPERTY/ BUSINESS OWNEROPERATOR/MANAGER OTHER UTHORI ED AGENT <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: o o c SQ <br />COMMENTS:DO N01DRAP0 <br />PAYMENT <br />RECEIV ED <br />MAR 2 6 2010 <br />LIIMENTALT' <br />SAN JOGAI <br />ACCEPTED BY: <br />,0 Ce vLC 19-4 <br />EMPLOYEE#: N 3 Z i <br />/ <br />H UA f -O <br />Z6 <br />ASSIGNEDTO: ��Q"�_ <br />EMPLOYEE #: Z( <br />DATE: 3 Z� O <br />Date Service Completed (if already completed): <br />SERVICE CODE: -5" <br />PIE: 3 (,, Z <br />Fee Amount: ,D <br />Amount Paid *,-2-3b. O L7 <br />Payment Date <br />Payment Type �j <br />Invoice # <br />Check # RS q ('IV <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />