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SAN JOAQUIN ._,OUNTY ENVIRONMENTAL HEALTH L L,PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />,5 <br />SERVICE RffiQUEST #1 <br />OWNE / OPERATOR e.rn 6 r poet tdoe..- HECK if BILLING ADDRESSn NM 7 . rilli eft .........- t_ _ t. - — _ , . <br />i °AI <br />_-_ i,_ AI = (45S6C.14IPT <br />FACILITY NAME L. AkEte 66 ) <br />SITE ADDRESS <br />‘9 Street Number Direction b0/5 5T F lel Name <br />1_,O 3 <br />City Zip Code <br />-Figl <br />OYMAltiNG ADDRESS (If Different from Site Address) <br />3 I Street Number L Street Name <br />STATE ZIP <br />?S.:2-y 1_, <br />PHONE #1 EXT. <br />(QiN) e61-q7oci <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />I BOS DISTRICT <br />I <br />11 LOCATION CODE <br />a <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />r-S A tke_ CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE ZIP <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, Sta S, S TE and FEE ws. <br />APPLICANT'S SIGNATURE: <br /> <br />tfleaPeAl DATE: <br />PROPERTY /Wit LiTti,ESS OWNE OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />. . <br />-•%k, :if:APPLICANT i no he BILLING PARTY, proof of authorization to sign is required Title <br />AUTHOftIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above..$Ie 'address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />inforCation teLthe SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />prokided to me or my representative. ENT 0 <br />TYPE OF SERVICE REQUESTED: /113/0630 i:ktCON/ <br />COMMENTS: <br />' <br />' <br />tANI 2 um COUN'il cp,s JO PsCANI,AEN <br />1-if-N;C‘4 "r <br />ACCEPTED BY: <br />ee4'11/X__ <br />EMPLOYEE #: 67;7_1_3 DATE: ..-- .24.Sy ite• <br />ASSIGNED TO: elleig,e( EMPLOYEE #: 4,44.5' DATE: <br />Date Service Completed (if already completed): SERVICE CODE: Lgal.,..1.-- II E: 4,10 <br />Fee Amount: ag-ti . CD Amount Paid lt..t 4, , 0 D Payment Date 5-7., <br />Payment Type ,77 Invoice # Check # i 0 03 Received By: ....i...1_ <br />END 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />Pke