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/ / 2_ / 2_•3 DATE: <br />TYPE OF SERVICE REQUESTED: <br />CotaMEI1TS: .„„er----- <br />- , <br />ACCEPTED BY: EMPLOY i EE #: i • • ' DATE: <br />, <br />ASSIGNED TO:EMPLOYEE , <br />— <br />tt: DATE: <br />Date Service Completed 'Of already completed): i f TiEFIVICe DUDE: P I E: <br />• _ i 6 • <br />Fee Amount: / I FA-41-o-utit 1;;Id 7)1 I Payment Date <br />' <br />7 <br />Y <br />Payment Type Invoice ti Check # Received By: <br />Et-ID 48-02-025 <br />REVISED 11/17/2003 <br />Tgii0 <br />SR FORM (Golden Rod) <br />( <br />ONO <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />1) ________ _ <br />FACILITY ID #i , <br />F.A66 0/5 ti-0 <br />SERVICE REQUEST # <br />.._,P,(ro ai 3 La <br />OWNER! OPERATOR CHECK If <br />-1—\) IDS Jks (— <br />BILLING ADDRESS 0 <br />FACILITY NAME .--) <br />-0 T\J tArv.. 4 1---,, tr,_Q_ <br />SITE ADDRESS <br />2 \-4 05" Street Number DIrectIon <br />YPC 74\Ar— <br />Sireotlifirm <br />S (ND ck4r)--•-\ <br />en <br />CI c 2 <br />zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />? 0 9,0 X )Th IS Street Numbor Street Hams <br />CITY STATE ZIP <br />s(ke el 5 --3—'--8 <br />PHONE #1 <br />I <br />EXT. <br />( Sto ) 3 0 el e70 APN Si LAND USE APPLICATION # <br />, <br />PHONE #2 EXT. <br />( ) <br />1731 OS DISTRICT 1 <br />I I <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR <br />krN(Y L ir \ 1 C if ) Il CHECK if BILUND ADDRESS <br />T <br />E <br />BUSINESS NAME <br />171 LC P/3? a) <br />PHONE # <br />( 5*.k <br />FAx# <br />I <br />) 3 '.-d-1 <br />Err. <br />0 1 54 <br />HOME Or MAILING ADDRESS PAY MENT <br />crrv STATE ZIP RECEIV <br />BILLING ACKNOWLEDGEMENT: I the undersigned property or business owner, operator or authorized fief <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated Arthis project <br />SPs"'" CCeNnatilNINEcNmuANELTNi or activity will be billed to me or my business as identified on this form. <br />j°1ARi <br /> <br />Cout•rrY Ordinance Codes, Standards, STA t and FED <br />APPLICANT'S SIGNATURE: 4111111 • try'‘• <br />PRoPERTr / BUSINESS OWNER0 OPERATOR/ MANAGER OTHER AUTHORIZED AGEN'r 0 <br />If 4 PPLICANT is not the BILLING PARTY, proof o authorization to sign is required TM. <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 envitonmentallsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI•I DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />I also certify that I have prepared this application and :at the work to be performed will be done in accordance <br />LAL laws.