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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> coos \ )oi <br /> OWNER/OPERATOR Sohiq CHECK If BILLING ADDRESS O <br /> �q�ue� <br /> FACILITY NAME So V, I �I —i� � 10 <br /> SITE ADDRESS 5�2 I ., ll l�l� ��' `i—jrll/ <br /> Street Num6u Dlrecflon 1 Street Ne I Y t� lc I C <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street NumWr <br /> CITY STATE ZIP <br /> PH0NE#1 ET• APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#P E> . SOS DISTRICT LOCATION CODE <br /> xQ )53 I- Z <br /> r� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Sonl iA \v7- -Z-- <br /> 61 WIf CHECK It BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ev' <br /> EI T� Ah'o 4 s31 - z3 <br /> HOME or MAIDNG ADDRESS FAX# <br /> CfTYFro/ STATE LP cbt g5-3.1 <br /> BILLINGA KN V ED EME T: L 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 t wor o e performed will be done in accordance with all SAN JoAQutN <br /> COuNrY Ordinance Codes,Standards,STA DERALla (� /t r��n <br /> APPLICANT'S SIGNATURE: DATE: "I "1 170 Y7/ <br /> PROPERTY]SUSINESSOWNER0 OPE /MANAGER O VERA O DAGENTO <br /> IjAPPUCMT is`not the BILLING PARTY proof of authorization to grt it required Tule <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 JoAQurN CouNrY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. IRA)4AV4 I. <br /> TYPE OF SERVICE REQUESTED: RE <br /> COMMENTS: SEP 1 <br /> 2012 <br /> SAN,/OAQUIN C <br /> HEALTH Df RRTM NTY <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: •\r-\\-\o\ ir e EMPLOYEE#: �,A S� DATE: <br /> Date Service Completed (If already completed): SERVICE COOE: Ob PIE: <br /> Fee Amount: 1 S Amount Pald Payment Date 22 <br /> Payment Type I cJ `I`n`voice# Received By: <br /> ' ojff7d <br /> EHD 4&-02-025 <br /> �a 1 1 p f�-o 1(0 ILAC SR FORM(Golden Rod) <br /> REVISED 11/1712003 - - 2b y I S <br />