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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property r ncR. TI(Q2(71 tAs-C lk 0 Softchic. <br />FACILITY ID # SERVICE REQUEST # <br />-7S'SZCI)1F1,04 1-2 <br />OWNER I OPERATOR k OCQUi ile t')G i S 4A.7- I AL, <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS <br />'U., 0 Street Number Direction OW ON creet "IaL :1)''A) K) 5kk.°3tTlifi <br />Cr "LCY-1 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Addreuj <br />V I r), (\i( '7)-"t)(- -:-) Street Number Street Name <br />CITY STATE <br />PHONE #11 Err. <br />(zi) 57-S' <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR i . <br />S ( rtICk <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME 1 i il(.1 , • + <br />M 1;,01f. qC,'". r.it, DAyrisc, a C <br />PHONE # <br />(201 ) <br />ExT. <br /><_1O - <br />HOME or MAILING ADDRE.SS HOME <br />. ii. 0 , b <br />CITY <br />4 lk71: kbcri <br />STATE (1 ZIP ri cru '',..) <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 ail FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />0- - <br /> <br />PROPERTY / BUSINESS OWNER k OPERATOR/ MANAGE 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> Title <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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />rovided to me or my representative. <br /> PA . <br />TYPE OF SERVICE REQUESTED: iri.Ciwill417. illets <br />COMMENTS: ---,- K t r <br />-, <br />r t.,4,,_,./) vt " (-)x /t -- 41,1 R 0 ? <br />:204 <br />81IN J0,4 Qu <br />netA.11/00ivi: COUNry <br />7.80EpAgNrAL - .TAfENT. <br />ACCEPTED BY: el EMPLOYEE #: (t, " Z___ 1 3 DATE: i ) 3 <br />ASSIGNED TO: , , <br />a-Ve-it— <br />EMPLOYEE #: cr K L t DATE: 2 • 23 <br />Date Service Compl ed (if already completed): SERVICE CODE: 4 d ,,,5 P / E: <br />Ivi / <br />Fee Amount: 1,k Amount Paid <br />illg c?).--- <br />Payment Date cl-i—V2-3 <br />Payment Type l• Invoice # Check # Received By: &bold <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)