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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Aet-} /V/"//. <br />FACILITY ID # <br />2 2 s <br />BUSINESS NAME <br />�.va.+•.:/ S4.r/,. <br />SERVICE REQUEST # <br />SQ 0DSS3Ro <br />OWNER/OPERATOR Q I�NSri <br />l�'�^T <br />eeS G L C— <br />CNECK If BILLING A00RE33� <br />FACILrrY NAME <br />lllt r cJsL S �� <br />FAX <br />( ) <br />CITY �a✓n.lr S <br />SITEADDRESs <br />Sheol Number <br />reeoon <br />AJ <br />Street Neme <br />by Code <br />HOME or NAILING ADDRESS (If Different fr m Slte Address) <br />N S 'b 'S�rt I.H Lv 7, Sheat Number <br />CGt W -/-LK 65C =EMPLOYEE <br />SPW Name <br />CITY.��— <br />F—arv.erc <br />ASSIGNED TO: <br />STATE LP <br />TK �?sz 9-( <br />PHONE #1 <br />(992 ) /0Z 7`(1 s Ht tP <br />APN# <br />LAND USE APPLICATON# <br />PHONE#2 ER <br />(21t1) F, -it 3?30 <br />SERVICE CODE: <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR Ci-ti7 <br />Aet-} /V/"//. <br />CHECK NBILLING AOORE33® <br />BUSINESS NAME <br />�.va.+•.:/ S4.r/,. <br />PHONE# �T <br />5-5L5 — 3�3e <br />HOME Or MAILING ADDRESS <br />`t/O J a�� r, ��,� �, <br />T r <br />FAX <br />( ) <br />CITY �a✓n.lr S <br />p <br />Or�we J� <br />STATE r-<- ZIP •�' SZ a <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 d that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE aD ERAL 1 S. <br />APPLICANT'S SIGNATURE: / Ga.- w DATE: <br />PROPERTY/ BUSINESS OWNER❑ /OPERATOR/MANAGER❑ i/ OrMRAUTHORIZEDAGENT60 `'"A 411#q .4 qe/ <br />IfAPPLlCANT is not the B/LL/NG PARTY. proof of authorization to sign is required T41e <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the prop located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environme t ssme. tt <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and �y <br />provided to me or my representative. Ver. <br />TYPE OF SERVICE REQUESTED: <br />.� 14 <br />/'I <br />COMMENTS: <br />✓O <br />IVO <br />Afr <br />ACCEPTED BY: <br />CGt W -/-LK 65C =EMPLOYEE <br />N: <br />DATE: _ Oq <br />ASSIGNED TO: <br />F=a 1A „ <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: ' �2 <br />Fee Amount: <br />5� — <br />Amount Paid /S-2 D� <br />Payment Date <br />ZZ <br />Payment Type <br />Z �- <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod), C) <br />C �� <br />