|
SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property
<br />R II /2 A z— RE 5 ID ---A/7-1,4 I--
<br />FACILITY ID #
<br />-120054.49
<br />SERVICE REQUEST #
<br />t/-7
<br />OWNER/OPERATOR
<br />5F-RAy /A/r/E-srfilEA/7- - - ectiTPAa /L-(! , CHECK if
<br />.7
<br />BILLING ADDRESS
<br />FACILITY NAME
<br />SITE ADDRESS /5-4, 5- 5-
<br />Street Number
<br />5
<br />Direction
<br />in/ 7-GHE-1-4- /212 .
<br />Street Name
<br />MA AITEc A
<br />City
<br />?5-336
<br />Zip Code
<br />HOME or MAILING ADDRESS (If Different from Site Address) 1+ 33
<br />Street Number
<br />cil . a 6r--Ar 0 1- V D • 71. 9
<br />Street Name
<br />CITY
<br />17/A ki -r-A
<br />
<br />STATE ZIP
<br />
<br />('Ac 9s-334
<br />PHONE #1
<br />vo9 ) 96 5' - /902 3
<br />Exr. APN #
<br />,../ 0 -194,0 - a io
<br />LAND USE APPLICATION #
<br />PA - c.-/0001-0 0
<br />PHONE #2
<br />( )
<br />EXT. BOS DISTRICT
<br />r. f
<br />LOCATION CODE
<br />q g
<br />CONTRACTOR / SERVICE REQUESTOR
<br />REQUESTOR -,
<br />3 _ 0/4 c-fe SNey
<br />CHECK if BILLING ADDRESS
<br />BUSINESS NAME
<br />CA46/kle-y CM./ 6Cle---r/A/
<br />PHONE # t EXT.
<br />HOME or MAILING ADDRESS
<br />PIP. 0 . 13o y 37 4)4-
<br />FAX #
<br />( )
<br />CITY
<br />""rligLocK
<br />STATE 4 _
<br />(....
<br />A
<br />,-,
<br />ZIP q 5 3 g 1
<br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of sank,
<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 FED laws.
<br />APPLICANT'S SIGNATURE:
<br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0
<br />DATE:
<br />/
<br />/-2/02•7171/
<br />W 0 ER AUTHORIZED AGENT IAA
<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 syy time it is
<br />provided to me or my representative.
<br />TYPE OF SERVICE REQUESTED: XCD 11F L) S-0 IL SU i TA g 1 Lt Ty T14 Dy )12E(AEuti
<br />irTt.-clEifril.41
<br />COMMENTS: ...... ,I
<br />0 1 '
<br />0,I0-1.?
<br />Zi sto ,,t.6i 17 , 1 1 ty or, 17, p er S S .. *ix veil v ,,,, , +ii 5-s . Dec ,
<br />if 1 SAN 4. 47 202/
<br />" i I I 1:4e. A f 1- Oil e '6 f EP ../..„, k•Ait,/ Q04, ,.. Loma 1,015 v. , Y) eedeat 4 ht,itr Roil/4f t;o4,4,
<br />/1 0p,EiV7AL 7)'
<br />-1,17-4f Eisir
<br />ACCEPTED BY: ..""---g,./._, Z__ EMPLOYEE #: DATE: i Vddid I
<br />ASSIGNED TO: illt)6 EmPLoYEE #: DATE: 13 /07,i /147,
<br />Date Service Completed (if already completed):
<br />.,_
<br />SERVICE CODE: S- d 3 P / E: ? Coo?
<br />Fee Amount: 4 / R Amount Paid ', 112_, 60 Payment Date
<br />Payment Type (I e Invoice # Check # 3 76 4 Received By:
<br />EHD 48-02-025
<br />
<br />SR FORM (Golden Rod)
<br />REVISED 11/17/2003
|