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SAN JOAQL. 20UNTY ENVIRONMENTAL HEAL1141/EPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER ! OPERATOR <br />CHECK if <br />(---- ett- <br />BILLING ADDRESS <br />FACILITY NAME <br />NC 11 C_+Ck'i vi A Poor+ mel.i-i-i. <br />SITE ADDRESS <br />I 6"O <br /> <br />Street Number Direction <br />STOC.14N+-0 <br />ili 0$0.1C Street ame <br />4 <br />City Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Crn, STATE ZIP <br />PHONE #1 Err. <br />-reAcy (dog ) Wag- 07 3q <br />APN # I LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DisTiacT <br />II <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />,-C-reF All PIACLNClitb CHECK if BILLING ADDRESS E1REQUESTOR <br />B uS1NESS NAME <br />C as-601 P co t; 4- P-ein D AAA so:9 <br />PHONE # <br />(?O7) S3 7 — lo5i2 0 <br />Exr. <br />HOME or MAILING ADDRESS <br />SdOD /11 01-SiAj-elr gel <br />FAX # <br />(go, ) S3 7 — 46-9 ? <br />CITY c eirek cA , 95-307 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, Standards, STATE and FEDERAL laws. <br />T'S SIGNATURE: Atit ,v1.1. DATE: 71te <br /> <br />Fq4P BUSINESS OWNER': OPERATOR / MANAGER ?lc' OTHER AUTHORIZED AGENT 0 <br />1,f APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />A.caltORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />er„..._4P4abeike site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />ft1T ation to the SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH DEPART ENT as soon as it is available and at the same time it is <br />ided to me or my representative. foot .c.?4 g_-_--J i,c) HQ_ f_2JL-(0 J•e,_ kik.v\J , <br />41E OF SERVICE REQUESTED: Ref 106 -kit 4- V Cr- 6 <br />'COMMENTS: <br />FAymENT <br />RECEIVED <br />JUL -7 2011 <br />SAN JOAQUIN COUts <br />ENVIR HEALTHONMENTAL DEPARTME <br />ACCEPTED BY: 0 c , ‘../ c i e_A-- EMPLOYEE #: 032 f DATE: 7/-7 i f f <br />ASSIGNED TO: 2G0 „eiik.._z_71t.- EMPLOYEE #: ..2-l2 DATE: -7 1 7/ y <br />Date Service Completed (if already completed): SERVICE CODE: 5 --2_ PIE: A 6,0 <br />,p <br />Fee Amount: <br />,, <br />12_4 L. Amount Paid g D,L4 ki _ o -''' Payment Date 7(-2 ( t ( <br />Payment Type L.-7 Invoice # Check # ( 3 (:).( -2..- Received By: ---ZiL <br />SR FORM (Golden Rod) END 48-02-025 <br />REVISED 11/17/2003