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SAN JOAQUIN COUNTY EN'V'IRONMENTAL HEALTH DEPARTMENT <br />SERVIC +' REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST# <br />L I�Nfl>%1 {.tom jl��,� �L1,N�r <br />3 - <br />-a 0 <br />914/17_ <br />OWNER / OPERATOR n. t I S / n i' �• <br />FACn.ITYN"1-NaKYt 60WICl 9MNCAA ti6-C, - <br />5MNti�4�' �-WNFtLL <br />SITEADDRESs <br />It�Z�-o Lr-• <br />� Ln . <br />t' <br />ShvelftnbpL <br />PjLeodonstreet <br />NOMBc <br />i <br />od <br />HOME or N11,A,1 NaA/DyDRESS (It D3Naroni f ni Slte Address) <br />1 � ID Ci • vlZ M -P • Stree4 Numbar <br />V Y k �•{ <br />fi ` Street <br />CITY 5 Cb ib �,) <br />STq�rp zip 5� s <br />PHONE#1 Exr. <br />(W) Liuq— Uut <br />APN# <br />LANDUSEAPPUCATION# <br />PHDNE #Z fir• <br />BOB DISTRICT , ( <br />Ltic"IN CODE <br />CONTRAC'T'OR / SERVICE RROUESTOR <br />ReCtUESTOR Al, <br />P„nrD Vft"; 0,CHEcxIfPJuJNrADDREs1 <br />pESTE <br />COMMEMr. <br />BUSINESS NAME/) tr..L fG(.M QtC LU <br />L tit- <br />P�V Lo lq-S� Exr. <br />horn or MAIUNa ADDiRESS <br />is 2A- Kbpd�s <br />914/17_ <br />(53D) U-1 L} - L S2.s- <br />/L A <br />CITYL RA <br />STATE ZIP 6' "91 <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 HEALTI3 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 FumtAL laws. <br />APPLICANT'SSIGNATURE: �— DATE: lid. t "11 <br />PROPERTY /13iISWESSOwNERD OPERATOR/MANAGER OTIiERAUTHORIzEDA6Ew IAIPt—cf Of 15p -eh- L, <br />If rlPPLlCAtJ7' /s not the 81uma PdR7Y proof of oualordzatton to sigh is required rime <br />AUTHORIZATION TO RELEASE IN,I+0I2.MATION: 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 HEALTIT DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OFSERwEREQUD: ��.c✓ p��/c g- Gtr ole ' Q�Ssn ��� f . �� <br />pESTE <br />COMMEMr. <br />yIS P? % <br />3.. 1- <br />914/17_ <br />_ ! - <br />X11621 <br />H Ftryt�Q Utv co <br />ACCEPTED BY: //�� <br />.G / d _ <br />EmPLOYEE : 7%� �y Q <br />DATE: <br />ASSIGNEDTO: <br />r <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): % 7P -;P <br />SERViCECODE: <br />PIE: 41-v�� <br />tree Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice <br /># <br />7 <br />Rece <br />ed By:� <br />MO 48-02-026 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />191,7 <br />ryh, <br />r <br />��r <br />