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SAN JOAQUI 'OUNTY ENVIRONMENTAL HEAL — )EPARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property
<br />a /47...,-/44/2-/-1,7
<br />FACILITY ID # SERVICE REQUEST #
<br />3Cg-)'13:-37 6 /
<br />OWNER! OPE CHECK if
<br />(
<br />BILLING ADDRESS
<br />FACILITY NAME
<br />
<br />SITE ADDRESS /757 Z„e../,,e-d--/ 76.,1e0t-r- C/C / -72%;?-.6.(1 /60- --5-73,3-'
<br />Street Number Direction Street Name City Zip Code
<br />HOME Of MAILING ADDRESS (If Different from Site Address)
<br />Street Number Street Name •
<br />a.,9-i-4
<br />STATE ZIP CITY deid,,A___, FE i3iiri,,,,,z—
<br />PHONE #1 . EXT.
<br />k
<br />( )
<br />APN # LAND USE APPLICATION #
<br />PHONE #2 ExT.
<br />( )
<br />BOS DISTRICT LOCATION CODE
<br />CONTRACTOR / SERVICE RE UESTOR
<br />REQUESTOR
<br />-;1" CHECK if BILLING ADDRESS
<br />BUSINESS NAME /( PHONE #
<br />(476 ) '9"/- 76f.
<br />Exr.
<br />HOME or MAILING ADDRES
<br />S /3=3 " ) C- -' 6a l-
<br />Fia#
<br />(q/b ) 4?/,-/-
<br />CITY cit.t (k,„-kli...,..7„/6„,
<br />r (Az
<br />STATE CP;4, ZIP ç2S''5/p
<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 or
<br />activity will be billed to me or my business as identified on this form.
<br />,),1 I also certify that I have prepared this application and that the ork to be performed will be done in accordance with all SAN JOAQUIN
<br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL 1 s.
<br />APPLICANT'S SIGNATURE: -r,c-e-A- ,26/24/ 41.72-'‘4 " • DATE: gA/A5
<br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT
<br />
<br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 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 />PR'Y NI I 4 •
<br />TYPE OF SERVICE REQUESTED: AtA) p 0 / 04 Al (ityLek_____ RECEIVED
<br />COMMENTS:
<br />AUG 4 2OO5
<br />SAN JOAQUIN COUNTY
<br />ENVIRO NMENTAL
<br />HEALT DEPARTMEN
<br />DEPARTMENT
<br />ACCEPTED BY: L i E ell EMPLOYEE #: 03 z 1 ATE: ti _c--) _Sr
<br />EMPLOYEE #: Cri V'-I& 7 DATE: i 6/ ASSIGNED TO: :j, 11:416tur c ,,,44.,,,,,,,,4 e- 5 6...c..)
<br />Date Service Completed (if already completed): SERVICE CODE: ..2 3 P/E: 56,0 /
<br />Fee Amount: f7 37Z 00 Amount Paid -$37 _, 0 D Payment Date Z7
<br />Payment Type Type l
<br />Invoice # Check # 3 3 --7 g- Received By: "lort
<br />SR FORM (Golden Rod) EHD 48-02-025
<br />REVISED 11/17/2003
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