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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Prope <br />7,401 <br />FACILITY ID # <br />SERVICE REQUEST # <br />?� <br />� ; nal '1'1 <br />� <br />10 , <br />APR 2 � 2ti2� <br />PERATOR` <br />OWNER / OPERATOR--/ <br />M-2 Dor�Y <br />//7s�U <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />J� L� _ <br />SITE ADDRESS <br />DATE: � 7/-! <br />V P- lr Q a <br />EMPLOYEE #: <br />it) V� <br />C <br />-305L4 Street Number <br />Di ion <br />Street Name <br />PIE. U t�a <br />CI <br />Zip Code <br />HOME or MAILING ADDRESS /if niffwre-t f.nm <br />Ritc Addrasel <br />�ame�� <br />CITY����STATE <br />S�treeN m er <br />ZIP <br />r <br />PHONE #1 ExT. <br />(2tp) <br />APN # r_ <br />LAND USE APPLICATION # <br />PHONE #2 ExT.BOS <br />Received By: <br />DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR `�/l! `�' „ c� �O / CHECK if BILLING ADDRESS <br />BUSINESS NAME --]!V / / C(.'u �ol lam"/'S a I ( -i (��J PNGV I 5� ! - 2 .2- <br />HOME or MAILING_AQDRESS <br />CITY n P il-"7 -, STATE 4�a ZIP q 5-307 <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 />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS ONVNER❑ OPERATOR /MANAGER OTHER AUTHORIZED AGE', 0 <br />If APPLIC,9NT is not the RILLING PARTY, proof of authorization to sign is required Title <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 time it is <br />,nrinri to me nr my re resentative- <br />TYPE OF E �STED: 1�olr �ICLa3IJn s�.t �i;C �_ <br />IFc;L.l1 h* < t^rW <br />v�1 s 61 LP._ I/1'!e,� - -roivI il <br />cOMREC�'� �d <br />APR 2 � 2ti2� <br />N .JOAQ�IMENT �� T <br />J� L� _ <br />EMPLOYEE #: <br />DATE: � 7/-! <br />^, <br />j� <br />ASSIGNED TO: 67 <br />EMPLOYEE #: <br />DATE: L/ /117/111/1 <br />J„ 1yj <br />Date Service Completed (if already completed): <br />SERVICE CODE: JG, I <br />PIE. U t�a <br />Fee Amount: j <br />Amount Paid #w� 06 <br />Payment Date <br />27 2� <br />Payment TypeA- <br />Invoice # <br />Check # Z��G� <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />(6'com <br />�' <br />