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SAN JOAQUIN ._,,JUNTY ENVIRONMENTAL HEALTH L ARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property
<br />40.69V-71",,ler171 40:4f /e.
<br />FACILITY ID # SERVICE REQUEST #
<br />vs_
<br />r-' DOCOLSO \
<br />OWNER I OPERATOR CHECK if BILLING ADDRESS
<br />,
<br />FAciuTY NAME 14c-\ 4--CNCS. 5-1-(. Ap
<br />SITE ADDRESS [ 6t c i
<br />1
<br />Direction Street
<br />
<br />tqumber
<br />Al A hLe I d o-
<br />Street Name
<br />- -{-,/ City Zip Code
<br />HOME or MAILING ADDRESS (If Different from Site Address)
<br />-.._.(7 ,4'i-_ A-S 4- k, a tie Street Number Street Name
<br />CITY STATE ZIP
<br />PHONE #1 EXT.
<br />( )
<br />APN # LAND USE APPLICATION #
<br />PHONE #2 EXT.
<br />( 1
<br />BOS DISTRICT LOCATION CODE
<br />CONTRACTOR / SERVICE REQUESTOR
<br />REQUESTOR
<br />/1104/i‘e— ell,•1,61
<br />CHECK if BILLING ADDRESS
<br />BUSINESS NAME
<br />C li e .a.. /4"-v/s PHONE #
<br />(,,io,-) 677---ire
<br />EXT.
<br />HOME or MAILING ADDRESS
<br />./04e° .9(e--k.- Al-Ve--
<br />FAx #
<br />JeP-A /7€`57 -- '-7' 2f
<br />CRY STATE a°9 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, St a dards, STATE and FEDERAL laws.
<br />APPLICANT'S SIGNATURE: DATE:
<br />PAWMENT
<br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the piloyeMitic? ctr,t,nthe
<br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmenial/SIt'e asseSS-ment
<br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same twit is
<br />provided to me or my representative. u
<br />/ -AN JOAQUIN COUNTY
<br />‘°/ / e- ,Z.f irp-eig ZeA/ C#6-6/6' - ' " " "-- * TYPE OF SERVICE REQUESTED: PINI",,n 1 , 1\11-/-d.
<br />
<br />f • ! .--_."),60._ -NT COMMENTS: „,2,707,0„.....` / ,.46,:•40,,,,
<br />-
<br />
<br />rc,001? wftik-4/4",i-e -X•••e, - 5(er'CW747 71/4' --- /?'"Vfe-e 4e---/e--
<br />41/14G- .4-1,0'07/7/?. /0 - r-tp/d 9e€ /e/e* -6z,--, e•Ivere, ev7/,05-il:)
<br />*-k-7/,.,-riAx-e--,e ,---e&---vi---.5.-77 "7441,40-,.., ‘/ 40'ef*/
<br />ACCEPTED BY: e...4-t_v-nA_C c--o EMPLOYE
<br />DATE:
<br />r#: DATE:
<br />ittl '61(41
<br />ASSIGNED TO:
<br />? 'e CLVal.-?..-G\
<br />EMPLOYEE #:
<br />Date Service Completed (if already completed): SERVICE CODE: _5--?.......3
<br />Fee Amount: Amount Paid 4 30
<br />PIE76„0 -2_
<br />Payment Date I f,-
<br />Payment Type ici) Invoice # Check # l /0 ,..---y -27 Received By: f 9
<br />PROPERTY/BUSINESS OWNER 0 OPERATOR! MANAGER 0
<br />
<br />OTHER AUTHORIZED AGENTX
<br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required
<br />SR FORM (Golden Rod) EHD 48-02-025
<br />REVISED 11/17/2003
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