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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />),Type of Business or Property <br />/V47/.4140 ?I'D 4:1- <br />FACILITY ID # SERVICE REQUEST # <br />.sizoo s <br />OWNER / OPERATOR A <br />/i7A/7.0\/ /J/4<i9 CHECK if BILLING ADDRESS <br />FACILITY NAME <br /> /12'4'(4) sty AR2F,!_Ess <br />,, /1/7/4/X7441/eeabilettarection Street Name City Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />AP N # I LAND USE APPLICATION # <br />7-,7zoPoO6 <br />PHONE #2 EXT. HOS DISTRICT 2 LOCATI9,NSODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR .-f' 6 - 4.,. frat-r 46 CHECK if BILLING ADDRESS a <br />BUSINESS NAME <br />4V-6." R41/17 46 JI /e - <br />EXT. PH. Al" 4:t / ii Wfer <br />HOME or MAILING ADDRESS 6--A„., <br />09 <br />,./L../.9...":,. 7 iK <br />Yeri/r "/V <br />F. . <br />. .;/) 9 ' ‘ 6761V Crry STATE 4-- 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 spec • ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be.billed to me or my busi ess identi a o this form. <br />at th work to be performed will be done in accordance with all SAN JOAQUIN <br />RA laws. <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER El <br /> <br />PERA SR AGER <br />1f APPLICANT is not <br /> <br />BL NG PAR7'Y, proof of authorization to sign is required Title <br />AUTHORIZATION TO RE "A E FORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereby author e 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 />TYPE OF SERVICE REQUESTED: /--7-*'. "--,,,=;',----- ."7".2) <br />COMMENTS: <br />RECE , <br />AUG I If <br />D141i" <br />i (11 <br />SAN J" <br />. EM, <br />--1L1r , <br />ACCEPTED : Wfil <br />. --'. e.---- <br />EMPLOYEE #-:-51,--"g-- <br />r/r. <br />DATE%.% e,./(7),,c" <br />ASSIGNED <br />( <br />TO: 7->"1'2 ---c; <br />EMPLOYEE #: ,55,-.:7c., <br />Date Service Completed (if already completed): SERVICE CODE: <br />Fee Amount: '-,,Z5(:). co Amount Paid ?' 30 Payment Date gl ,q. / a cf <br />Payment Type V Invoice # Check # 3S-s--14 <br />- <br />Received By: Li3 <br />I also certify that I have prepared this <br />COUNTY Ordinance Codes, Standar <br />on and <br />and FED <br />DA1T/7 4 <br />OTHER AUTHORIZED AGENT El <br />61 <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)