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TYPE OF SERVICE REQUESTED: PO G L- (-1 "/1- / "---E i k - ( 0 .tiEe A__ A ---iv C L "f--( F.- C-K__
<br />COMMENTS: STOT PgtA 1 N 5 tr
<br />NCIA/ 51-011 Kc 'Y AAA. kottrivirki
<br />V &IS C/c)VZ.g.S,
<br />t W,v5/
<br />1 Ne.1"/ TiairS:W.,te , 111-4.-- DtertA/041110
<br />fl AND Oil 1-5 (111-6- i a k.., )1.0-‹.. r4M4.4Ay I
<br />G,.33, AGA-, REC
<br />JUN I
<br />-7.4,146: V
<br />ACCEPTED BY: cc) (_ ( ‘,..) s,..__ r i2_,01- EMPLOYEE #: 0,321 DATE: 6/ 4 J vAcc.
<br />ASSIGNED TO: t..0- j/2 -a el- EMPLOYEE #: 2_42, DATE: T171
<br />Date Service Service Completed (if already completed): SERVICE CODE: s- 2,2_ PIE:
<br />Fee Amount: g• 23 0 , iii) Amount Paid 'IS .23) . 0 D Payment Date 4::,// 0
<br />Payment Type L Invoice # Check # i q'Frj Received By: .2,,e(
<br />ENT
<br />IVED
<br />0 2010
<br />UIN COUNTY
<br />NMENTAL
<br />EPARTMENT
<br />SAN JOAQUI 'OUNTY ENVIRONMENTAL HEALTH L'ARTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property
<br />PAK-TIM/ kir citt Poi, ri,4:Y
<br />FACILITY
<br />(2 V
<br />ID # SERVICE REQUEST #
<br />,
<br />OWNER / OPERATOR sal--;:› , '"
<br />le-1-4 4 '7:::, 0 K rts-
<br />-R.0 .34, RT. trait -, N DRES
<br />FACILJTY NAME Nalf<T44 elet 1.-- _ covvvon 6)1/41 5
<br />SITE ADDRESS 5 I 0
<br />Street Number Direction i \I 01'12:7n4 ertJel,:re: b k 1 ,tig
<br />Li i ji , rre; , ji.,, I vfortio ; Tt..4.4-1.
<br />61,534
<br />Zip Code
<br />HOME Or MAILING ADDRESS (if Different from Site Address)
<br />1.q 00 Street Number c * i I tegAtakinit:ki :be: V*, Cm,
<br />- "K-AL ,,,,, -4 I, 1,,,,,A
<br />STATE ZIP
<br />PHONE #1 Err.
<br />204) ci 8.6, ci cl. bi
<br />• APN * LAND USE APPLICATION #
<br />PHONE #2 ( A EXT.
<br />Z4071 ab 16„i-z__. BOS DISTRICT ,, LOCATIENtODE
<br />CONT
<br />REQUESTOR
<br />CHECK if BILLING ADDRESS
<br />BUSINESS NAME PHONE #
<br />( )
<br />Err.
<br />HOME or MAluNG ADDRESS
<br />_ 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 th the work to be perform will be done in accordance with all SAN JOAQUIN
<br />COUNTY Ordinance Codes, Standards, Sr an*FED 'ws.
<br />APPLICANT'S SIGNATURE: DATE: / z at 0
<br />PROPERTY / BUSINESS OWNEX OPERATOR / MANAGER OTHER AUTHORIZED AGENT El 0 $140 Ai 144,,„„,
<br />If APPLICANT is not the BILLING PARTY, proof f authorization to sign is required
<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 />provided to me or my representative.
<br />Title
<br />EHD 48-02-025
<br />REVISED 11/17/2003
<br />SR FORM (Golden Rod)
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