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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />RVICE REQUEST # <br />S 00s1022(p <br />OWNER OPERATOR PRT �/ � �Y'L C / NV 7 / 1 CHECK If BILLING ADDRESS <br />FACILITY NAME G f t L 7-U 5� /1�l L- FOO J G L <br />G <br />SITE ADDRESS (3 o I <br />Street Number <br />Direetion <br />S / SC.�[ Ramewo <br />Street Name <br />ZIP S2 06 <br />L d,D1 J C <br />city <br />(; C <br />�1J2 "I <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) J I 1-41 <br />"(Street Number <br />SERVICE CODE: S-2-2 <br />1- %� T G v %� <br />!/ G /Sttrreet Name �/ <br />CrrYS/ o C K Tb N <br />Ew ZIP n �� <br />PHONE#1 Err. <br />(209) 362--2- 3() <br />62-230 2 <br />APN # <br />Payment Type <br />LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />Received By: <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR PRT' /�I�C(�' <br />\ 1AA01 / CHECK If BILLING ADDRESS <br />V <br />�l'/ /r J I t.yl <br />BUSINESS NAME Col, <br />lJ (� (//r <br />II D 1 %' <br />r (�(� <br />PHOo# En. <br />(a ) 2012-2-3o'2- <br />02-23x2HIOME <br />HOMEor MING ADDRESS <br />�uI <br />1 L D( <br />FAx# <br />) <br />_LC <br />CITY I D 1 )OPSAT <br />ZIP S2 06 <br />BILLING ACKNOWLEDGEMENT: 1, 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, STA and FEDERAL laws. / 2 <br />APPLICANT'S SIGNATURE: J O/" o6 J 2o2-3 <br />2 <br />Tt% <br />PROPt.RTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is Not tile BILLING PAR TYproof ofauthorization tosign isrequired 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 a6the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: W'evi �, I C� <br />:eM. �. ��CpPrt i I��ii � <br />S,q,,,o Q ° 6 z�'2.� <br />MATHO� 4 7 t Ty <br />ACCEPTED BY: I tV V - <br />EMPLOYEE M <br />DATE: I - <br />ASSIGNED TO: C <br />EMPLOYEE M <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: S-2-2 <br />PIE: ( O <br />Fee Amount: 4-702— <br />Amount Paid -=f-0a _- <br />Payment Date I (Q <br />2 3 <br />Payment Type <br />Invoice # 2011�� I <br />1L <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1111712003 <br />