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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />RECEIVED <br />SEP 01 1011 <br />SAEN (RONINOALN <br />Y <br />HEALTH DEPART ENT <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />OWNER/OPERATOR <br />_ E f2 got-) <br />CHECK NBILLING ADDRESS � <br />FACLITY NAME <br />)V/C <br />SITE ADDREss <br />Set.x Numper <br />I <br />SVF-3 <br />STD G1 -V/V <br />C1i5ZO% <br />HOME or MAIUNG ADDRESS (N Different horn She Address) ,Z-7 1 <br />SD..t umbr <br />✓�. Is'rT� A r r, ))/ / v� [L� /� <br />aVr I r//v W/vL.. /1 `r l_ <br />CRY TT3f,C� <br />`/f <br />STATE ZIP <br />CA r� <br />(//"r <br />PHONE#f Es. <br />( ) q10 zg33 <br />APNf <br />Io$ -130-2 <br />LAND USE APPIJGTION# <br />2z -0(o( <br />PHCHE 92 Ee'. <br />I ) <br />ROS Daimler LCICATON CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR IEy, <br />fl'� • IllNr CNECKRBILLMG ADDaE99 <br />,y <br />BUSINESS NAME ^J C I N V I /1�C <br />FIpIEf <br />HOME or MAILING A' DY RES$ <br />FAX# <br />tL <br />I ) <br />�.,.-�.�)N <br />Cm S i 0 `-t`-' d lr / `' STATE C'9 LP pl 5 Z () <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 />1 also cenify 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, STA'rh and IF laws. t <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERT'/BUsINEss OwwERj3 OPERATOR /MANAGER❑ OTHER AumuntizrD AGENT❑ <br />/f APPL/CIAT is not rhe BILL/NG PARTY. proof of authoriradon to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 envimnmentallsite 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 SERwcEREQuessm: I,VST,11-1 <br />T' s C4,1— 0-ue-1 1T—Ct Ir <br />COMMENTS: I N sT/ I l l 3 c o rv%. L i m 4 rvr S) ,\,jK , I /"-vO L-) A& H s <br />Pje -1P t. r'u2 f-tfATTNG PrP FtC40 dNLy K)D CUOICIejo( <br />Sc n-Gc PZ4/L -Nt'f- FUv(JS, N6 -040S 140T,00GS) P9lF'rZ-&Ls <br />-j�TYr <br />ACCEPTED BY: Ck qykic s G'Q <br />EMPLOTEE #: DATE: R <br />ASSIGNED TO: <br />EMPLOYEE#: DATEX'1— <br />`PIE: <br />Date Service Completed (N already Completed): <br />SERwcEcDOF: S�2' 0 <br />Fee Amount: _0 <br />Amount Pal (� UV Payment Date Z� <br />Payment Type I Invoice# <br />Chock#lq-'?L ^ R btsid By: <br />.y <br />qW U KK N M 0 ML� CW GE S, rz,&-�- <br />