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0 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />FILE COPY <br />Type of Business or Property <br />TZh,,SPO TYIUG%i1/�C> <br />FACRITY ID # G U/ <br />�D / I <br />pSEERVVIICCE REQUEST #-7 <br />JVDCC)7�,rjC) 1 <br />OWNER/ OPERATOR <br />ILL w6 k b}J ( <br />CHECK If BILLING ADDRESS <br />FACILITY NAME Yt L tT.6• l (7 W 1 <br />BUSINESS NAME (�1 <br />Lo�fS `7 6t-1 �66rLnYL <br />SITE ADDRESS I !> S <br />Street Number <br />Direction <br />P E5 C, Al a E 20 <br />Street Name <br />HOME or MAILING ADDRESS V&D -L S tJ CO Q O AT <br />fLA vy <br />C <br />a1 S Z 09 <br />zip cml. <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />CITY <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 Exr. <br />( I <br />APN# <br />LAND USE APPLICATION# <br />PHONE #Z EXr. <br />BOIS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTOR <br />S[ eA l 1 GO I J 811 <br />I,A%'ra,L V6s DC3CL floeI ^LS• ID Z &o oe- GA IWr)I& iLS-ZieR <br />CHECK if BILLING ADDR <br />Adis CaAJG47 &VAM ort, 4ZAot,4n SP.o46 fron Oral) Ta L-1gT <br />L&TLS <br />BUSINESS NAME (�1 <br />Lo�fS `7 6t-1 �66rLnYL <br />f 1J [� <br />PHONE # <br />, <br />Ez . <br />SZz• SIlO <br />HOME or MAILING ADDRESS V&D -L S tJ CO Q O AT <br />FAx# <br />ACCEPTED BY: <br />CITY <br />STATE Ck <br />LP 6W r=1ZS�t"1 <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 id tified on this form. <br />I also certify that I have prepared this applicati n a that the work to be performed will be done in accordance with all SAN JoAQurN <br />COUNTY Ordinance Codes, Standards, STATE F laws. <br />APPLICANT'S SIGNATURE: DATE: 3 - ZO <br />PROPERTY/ BUSIINFSSOWNER❑ OPERATOR/MANA ❑ OTHER AUTHORIZED AGENT Qt1A'j' _ MwAAl�ii <br />{f APPLICANT is not the BYLL(Ndi PANTP p1:11'of maitorization 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 environmenta/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. 111M 0/0 h <br />TYPE OF SERVICE REQUESTED: <br />I,A%'ra,L V6s DC3CL floeI ^LS• ID Z &o oe- GA IWr)I& iLS-ZieR <br />COMMENTS: <br />Adis CaAJG47 &VAM ort, 4ZAot,4n SP.o46 fron Oral) Ta L-1gT <br />BAR 2 <br />'44NJOA N <br />H LTHoH <br />ACCEPTED BY: <br />EMPLOYEE III: <br />DATE: <br />ASSIGNED TO: r—cc <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (if already Completed: <br />SERVICE CODE: <br />PIE: <br />Fee Amount: t+17 <br />Amount Paid 44)1— <br />Payment Date <br />3/,;' 1 <br />Payment Type iSInvoke# <br />I <br />CMe" � 32&go <br />1 Received By: /,j <br />3/t / t 1 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 <br />MENT <br />fVED <br />11017 <br />It <br />E�� <br />A e;Ar <br />