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P (Zos23 � (01 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERAT R -`n' 71 -( E] All J � V " nAf—PA CHECK if BILLING ADDRESS❑ <br /> FACiuTYNAME NEW :ZNQ/AN SLYPEk2MAkKET <br /> SITE <br /> ADDRESS w 1 • T A WG1 — C A C t e <br /> 117S-3.76 <br /> 3LSlJ Stmt Number Dlncaen 'y StreetName Cit 7 Zip Code <br /> HOME or MAIUNG ADDRESS (If Different from Site Address) <br /> Stmt Number Str..k N. e <br /> CITY STATE ZIP <br /> PNONE#I En. APN# LAND USE APPLICATION# <br /> 14D�) 644 G <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> 1 0 ) 2 - 2939 <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR J9.4., yc EU �L,A�A CHECK N BILLING ADDRESS❑ <br /> BUSINESS NAME "E •IWC- ULN�1 A N1 s,UP E2/t1 AQK UT PHgNE 6 y 9 4 <br /> HOME or MAILING ADDRESS FAX# <br /> 3250 7QRc 6A 4A^ 1 ) <br /> CITY (1 w1 STATE ZIP <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,S TE and ERAL laws. <br /> APPLICANT'S SIGNATURE: V v7 DATE: O 22 I D-wD 2.2- <br /> PROPERTY/Bust NESS OWNER IW/ OPERATOR/MANAGER ❑ OTHER AUTI1ORIZED AGENT <br /> J"APPt./cAAT is nor the BILLING PARTY proof of authorization to sign is required Tilt:�P�AY�MENT <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property- o <br /> lcafebMT iRe <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental�i Lardisrgpgt) <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the Same time <br /> provided to me or my representative. 5AN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: St�bAj Pec- v " /Fav,,„ to pKJ rev-cJ ��y &LT`JVjICq <br /> VA-u- <br /> �S . <br /> 27 is Cat" " PAM ( PU21 -�'7AGL" NDNEA7 )Ns � XIDP44I_ Jd,irh <br /> lb-P,A LY gssewALI &r-P6t AIL" 13 mAi as-k A-La-WS <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: ���,�� .e EMPLOYEE#: DATE: ^^ <br /> Date Service Completed (if already completed): SERVICE CODE: V 1 P/E: \�''VZ <br /> Fee Amount: ` Amount Paid Payment Date Z 2— 2.2 <br /> Payment Type l 1 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S <br />