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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/77 1Paile fivn76 eARK <br />FACILITY ID # SERVICE REQUEST # lowNq/ <br />OWNER / OPERATOR <br />#41201..0 CHECK if BILLING ADDRESS Er <br />FACILITY NAME <br />(20teiVral roAA/012_ 7via1?a_ Es-rArs <br />SITE ADDRESS 1 7 26-7, <br />Street Number Direction <br />NI) rRemiEway A D. <br />Street Narife <br />4aekeir-o20 <br />City <br />9 ca?7 <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 7(a+ <br />Street Number <br />05p/rAL Ro • <br />Street Name <br />CITY/. <br />YA 4- Ley f'rzi..44s STATE ZIP <br />a .95-16- <br />PHONE #1 Ex-r. <br />(07 07 ) 3a7 - o 716 <br />APN # <br />aci- )c-'-(.4 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LocATiow <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR D oN el-}E5NF-y PE CHECK if BILLING ADDRESS <br />--- BUSINESS NAME / , <br />CP ESNEy GoNsui--ON <br />PHONE # , <br />(.9f)4P.2-/G,52 <br />FAX # <br />EXT <br />HOME or MAILING ADDRESS <br />CITY 1t4rZZA) az- STATE OA' <br /> <br />ZIP (5, r3 de / <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 app!. tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, and FEit laws. <br />APPLICANT'S SIGNATURE: DATE: //- <br /> <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / ANAGER 0 THER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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: 40 w/-6 i?Ef.g4 ie el-/ Xer0/Z7 li,;11147 AIT <br />COMMENTS: <br />c " v <br />p(cor, L__ ks-9-e 1-',." itjAt I <br />'202, 'IA/Jai .-ttill Quitvc ti_ AP ROA% OUN.,, —11- r/1/ D c..0 fS-Altit. i r <br />ACCEPTED BY: i <br />7 <br />EMPLOYEEA-- #: (A) ,,L5 ilfz://v <br />DATE: <br />2,_ <br />ASSIGNED To: EMPLOYEE #: DATE: 6/ /,_ ( <br />P i <br />E <br />: 4 10 I Date Service Completed (if already completed): <br />, <br />SERVICE CODE: 5'73 <br />Fee Amount: "30 L-I-- Amount Paid ,3.32-1.•--- Payment Date (al ii'1124 <br />Payment Type 0//01.4 Invoice # Check # 3-4/c Received By: eteil. <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)