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JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />WOMIAN <br />S� SERVICE REQUEST <br />is <br />Type of Business or Property <br />FACILITY ID # <br />-Z <br />ZI <br />COMMENTS: <br />SE Q, <br />Ve' <br />RECEIVED <br />DEC 12 2003 <br />I <br />SAN JOAQUIN COUNTY <br />5 P-6 13 0 3 1 ;7 <br />lid fret a / <br />ENVIRONMENTAL <br />OWNER / OPERATOR <br />ACCEPTED BY: <br />CHECK If BILLING ADDRESS <br />t f O /Cy tL/0 <br />EMPLOYEE #: Q 3 <br />DATE: <br />U <br />FACILITY NAME <br />T <br />EMPLOYEE #: 3 S 8 v <br />SITE ADDRESS <br />I <br />�7Uh- � <br />s'}OG,t+off <br />g5zo z_ <br />SIp <br />D 1 l Street Number Direction <br />Street Name <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address)(xy <br />6 <br />T\ dip , <br />�N �5at <br />Payment Type <br />Street Number <br />Invoice # <br />reet Nama <br />�_ 1 <br />CITY1- ` e( M i n <br />w INET' <br />$TATE ZIP <br />i <br />PHONE #1 <br />APN # <br />LAND USE APPLICATION # <br />('Zo4) 91-1 ( -? S 6 1 <br />(3 -1053 l Ll <br />PHONE#2 EM. <br />( ) <br />BO$DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />En vlro/1 man 40 ( r n a4confrachnJLnc . <br />BUSINESS NAME PHONE# EaT. <br />I par Ce'nt`er 19rtUv /t( 66 ,230 <br />HOME or MAILING ADDRESS Fax# <br />Sante '1 - CA (Tri) 6G��23/d <br />CITY STATE ZIP ,� Z O <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 />COUNTY Ordinance Codes, Standards, STATE and FEDER 1 <br />APPLICANT'S SIGNATURE: DATE: I Z //Z �0 3 <br />PROPERTY/ BUSINESS OWNER EI OPERATOR ANACER❑ OTHER AUTHORIZED AGENT® C6h5UIi4r1',� <br />ffAPPL/CANT 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or enviromnentaVsite assessment <br />infomtation 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: (% ST rn ot/a-PAYMENT <br />COMMENTS: <br />RECEIVED <br />DEC 12 2003 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />P V'6N <br />EMPLOYEE #: Q 3 <br />DATE: <br />U <br />ASSIGNED TO: <br />T <br />EMPLOYEE #: 3 S 8 v <br />DATE:' Lf ( Z <br />D ate Service Completed (if already completed): <br />SERVICE CODE: <br />03 <br />PIE: 23� <br />Fee Amount: <br />Amount Paid <br />q r <br />Payment Date 1 f <br />Payment Type <br />,/ - <br />Invoice # <br />Check # 1 ��2 <br />Received By: 4 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 - - - <br />