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SAN JOAQIbr. COUNTY ENVIRONMENTAL HEALTR--JEPARTMENT <br />SERVICE REQUEST <br />T of Business or Prop <br />CNr: H BN Amo iess❑ <br />Buspa 3NAw <br />SR e ire uv„ vQ� i0vi <br />FFA/CILfiY ID ti SERVICE REOUM # <br />�1 i N2 JI SiN <br />{� <br />' eC I' <br />d <br />I\erty <br />V S900 V <br />L45OPEPu -1 �I o neKABiWNGAOD33❑ <br />SAN JOAQUIN COUNTY <br />RE <br />'71's <br />14SITE <br />ENVIRONMENTAL <br />ADDRESS <br />EP t <br />ACCTED BY: 1 t - - <br />Hcir I rpoSQ <br />Rd <br />(�. �p <br />Sok 1 -on <br />q 5� <br />Sane NunEer <br />.� <br />z� <br />DATE: , L L r <br />Date service Completed (H already compieted): <br />SERVICE CODE: Z.?)DQ <br />PIE: <br />HOPE or ItlAiuw ADDRESS (Ir Different from <br />Site Address) <br />(�tleilILo n o <br />ID5 <br />Su"tNum <br />V <br />Sbeetft. <br />Cm/I <br />� 42W6-tr 'j:�&rk <br />Received <br />1� /3a -L7 <br />PI1DIE=1 En. <br />1$05) 5a <br />APN • <br />LAND USE APPUCAnom a <br />PWK#2 Em*. <br />(5s9, 5$5- 8► 5� <br />SOS DtsTtacr <br />Loc*noN COGS <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUEST <br />�`._ .1'. (As _ <br />CNr: H BN Amo iess❑ <br />Buspa 3NAw <br />SR e ire uv„ vQ� i0vi <br />`yrs: iegse- send- Perm -. �ru(c� Rc rues+Or <br />PMWS Ext. <br />9 585-815 <br />HOME or NALmG ADDRESS <br />303,4 N. G10C:Ie.r <br />Fax • <br />(5s91585- Qq 49 <br />Cm I I0 Y[�' rd <br />>—r , V <br />STATE l/1 n Zr <br />.Ji 93aa � <br />BILLING ACKNOWI_FnGEMFNT: 1, the undersigned property or business owner, operator or audiarized agmt of same, <br />acknowledge that all site and/or project specific ENVIRONMFNTAi_ HEALTH DFPARTMF.\7 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 perl'ixmed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: dS DATE: <br />PNorrim / BUSmNEss OwNKRC}r OPERA / MANAGER ❑ OTHERAUTW)m7EDAGENT O <br />//APPLICANT is not the BILLING PARTY proof of authorization m sign it 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 authoruc the release of any and all results, geotechnical data and/or environmentaUsHe 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: <br />`yrs: iegse- send- Perm -. �ru(c� Rc rues+Or <br />I I <br />," IC22U¢J'�r �y•,.E{, ani Ques'�iona or Cpncervn <br />U <br />DEC 2 7 2004 <br />(U� <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />Q <br />DEPARTMENT <br />EP t <br />ACCTED BY: 1 t - - <br />EMPLOYEE tF. <br />(�. �p <br />DATE: 12 <br />ASSIGNED TO: <br />EMPLOYEE ar: <br />z� <br />DATE: , L L r <br />Date service Completed (H already compieted): <br />SERVICE CODE: Z.?)DQ <br />PIE: <br />Fee Amount: ', <br />Amount Paid _ <br />Payment Date <br />Payment Type <br />Irmvoice • <br />Cheek x O <br />Received <br />EHD 48-02{125 <br />REVISED -0 -025 2003 SR FORM (Golden <br />I <br />