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SAN JOAQL.,... COUNTY ENVIRONMENTAL HEALTH L .PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />n i . 1 i <br />Mo Crut r of ii-o al t paii.< <br />FACILITY ID # <br />f r i4..oct),_.)„,,c6 <br />SERVICE REQUEST # <br />S IL (DO -7 9 'IS Y <br />OWNER / OPERATOR <br />—7 r 1' I G M <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />SITE ADDRESS / <br />Street Number <br />tr- <br />Direction <br />V CI of-f-ct tine M reet Na MO fee ct City <br />Q4-336 <br />ip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 at <br />;2 051) 6L0 —02 3 ? 5 <br />APN # <br />,)D loLi0 1-10 I LAND USE APPLICATION # <br />PHONE #2 BT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />R_U_EJ S T OF <br />— / raciterY1 0/14 POO/ A Lc0 a JAC, / i /1.4 krey CHECK if BILLING ADDRESS El <br />B__49XU ES;,,JAME n 1 0 (-) <br />""-- 1 r q riY) 01 f 1c'. r-1.20 i Ox ',-10 e, ietz.. <br />pHoNr # <br />(0)36 <br />XT. <br />HOME ol.,•MAL! ADDRESS. <br />r <br />.-1 <br />FAX # <br />( ) <br />CITY $0 a i 1 <br />07 STATE c . ZIP 9,0 6 8 <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 />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 />kfrt. ' <br />cli <br /> DATE: 08 - o 6 -/E .i. <br />PROPERTY! BUSINESS OWNER 0 PERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Iffk <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 above <br />site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessme..ftiktirr_nation <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is prOZAW4tar <br />my representative. <br />TYPE OF SERVICE REQUESTED: --"?--cif) a. 1 <br />(--)1 ..C/r114.1, <br />r .V—i) i 0 &Pi r icu'l rjLk((1--. AOG 0 <br />COMMENTS: 84V 8 20/8 410,4 I QUA, N <br />ititit il'ON °Du ricip p41002/7) <br />ART4,1k Ovr <br />ACCEPTED BY: (..:e( \ yti EMPLOYEE #: DATE: ''t 3 <br />ASSIGNED TO:lAcp...et I )(') <br />EMPLOYEE #: DATE: %S. . 1 5)/ <br />Date Service Completed 'if already completed): SERVICE CODE:,a, .._, _ P/E: <br />Fee Amount: -__3 0t-i GC Amount Pai 3,y4 o() Payment Date <br />Payment Type 444_ Invoice # Check # 7pq‘ 0 Recei ed By: <br />COUNTY Ordinance Codes, Standards, STATE and FEDpAL W <br />APPLICANT'S SIGNATURE:d <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />07/17/08