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SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH k) RTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property —7_ <br /> se� vic S��� ian T D7 <br /> OWNER/OPERATOR CHECK N BILLING AOOResSQ <br /> FACILITY NAME {.� / <br /> SITEAaoRESS yoSQ INS 1`e /'fG.7 t eG 9s��6 <br /> YY 5ticefnumBm ni�uctlon 9t tNamu Citya Tf Cedu <br /> HOME or MAILING ADDRESS (N Different from Site Address) <br /> uuul NumMr 54w1 Name <br /> CITY STATE ZIP <br /> PHONE#1 // APN# LAND USE APPUCATION# <br /> 77a. <br /> PHONE#2 E**• BOS DISTRICT LOCAnON toes <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR � /VI // CnECK if t3lwNG AoopESS <br /> RK <br /> CXye <br /> 7' ! PHONE# W. <br /> BUSINESS NAME C'e �6i 6 ,- 7 '14 O <br /> HQMEor MAIUNGAD RESS ` Fax# <br /> ;Z %00 ®J'rlwnd 46e' (sG/139 .3 - ? 3 <br /> STATE ZIP <br /> CITY aif Fran c r-S c c C G. 9 4// .? <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMEm 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 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 OrcGnanc'e Codes,Standards,STA�TE�and FEDERAL laws <br /> L . <br /> bw" <br /> APPLICANT'S SIGNATURE: DATE: ��•• �.r�, <br /> Pnot-Ea'I'Y/13USINMS OWNER❑ OPERkfoR/NlANAGE14 ❑ O'I'tIER AUTHORIZED AGLNI'2?e1 '/�viJ <br /> IJ APPLICANT is nal the Hf/.flNGPARI proof of authorization to sign is required Tltfe O <br /> AUTHORIZATIONTO 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, geolec finical 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 Sime it is <br /> provided to me or my representative. - <br /> TYPE OF SERVICE REQUESTED: / RECEIVED <br /> COMMENTS: // I- 41-P 7 Ta,,k APR 2 6 2008 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTEgTQ: /_ <br /> EMPLOYEE#: DATE: <br /> ASSIGNEEMPLOYEE#: r�G D DATE• <br /> Date Seeted (N already completod): SERVICE CODE: PIE: <br /> Fee Am85 .D 0 Amount Paid Payne Dato <br /> Paymeny Invoice# jih6ElrC-# Received By: <br /> �n�j(/✓I ,2qj r 13 SR FORM(Golden Rod) <br /> EHD 48.02.025 <br /> REVISED 11/17/2003 <br /> L0/Z0 39Vd -HIH >10IlHU CZ9666ET99 bE :TT 800Z/1Z/b0 <br />