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TYPE OF SERVICE REQUESTED: <br /> <br />COMMENTS: 14 1,\A eAD cx.x..,.s..,,..A . 6 _ . . . ) y-11 4101/ <br />I 8 <br />414 f a <br />ll414""RO VI* C rips 1V4t. C <br />iikyo, 417; <br />.14744 <br />ACCEPTED BY: Ve.....S EMPLOYEE #: DATE: ( a ,- 1)1'7° <br />ASSIGNED TO: V-C) EMPLOYEE #: DATE: <br />Date Service Completed (If already completed): SERVICE CODE: 0 G i PIE: kcicyl <br />Fee Amount: 10,0 2, -- Amount Pai# /is-20D Payment Date I 1 1 g/z0 <br />Payment Type . e )c Invoice # Check # :;....2....6--7 ,,i--/ Received By: <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 ti u04 <br />provided to me or my representative. <br />I <br />PR or525q0L+ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE RE UEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />G,o3g2 otos <br />OWNER! OPERATOR <br />Will t'A- net oR R.4 q r..) tr re..,,ft I <br />CHECK if BILLING DRESS AD rd <br />FACILITY NAME <br />SITE ADDRESS <br />I LI 0 -3 Street Number Direction <br />STe_ i A •e EA_ L. R4._ <br />-Street Name <br />ESCAL-0 ii <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Exr. <br />OM') € 3 €. D, <br />APN # <br />„Iv 7- t o — P-1-- <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUE&NR' c'-' <br />---)-1-4-A-17: <br />_ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />Will\ i at/V ( 3- 4.L.- c-----)-62/IA-a_,G.- <br />PHONE # <br />3c6, )---- <br />EXT. <br />HOME or MAILING ADDRESS - <br />190 -3 <br />FAX # <br />CITY 0,1_,Gy__\ 0 STATE 0_4___. ZIP e7S — 3 c)._-0 <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, STATE and FEDERAL laws. <br />DATE: ////4/c)44 <br />PROPERTY / BUSINESS OWNER Fp OPERATOR / MANAGER 0 OTIIER AUTHORIZED AGENT 0 <br />f APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />APPLICANT'S SIGNATURE: <br />Title <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)