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RECEIVED <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT AUG 13 2014 <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID 4 <br />SERVICEREtlKF/,3 FAL H9 <br />b <br />3 <br />HOME Or MAILING ADDRESS /' ! �D <br />7 H-I,r3-rs�trc t2� <br />S12ao 7c� 3z� <br />OWNERIOPERATOR G <br />I 1 �- <br />/r'�� <br />CITY l� /� ��-� <br />CHECK If BILLING ADDRESS <br />FACILITY NAME �`ro.G fl LP <br />HE.ALT}IEhMRp�TM� <br />ACCEPTED BY: �� ��L` <br />SITE ADDRESS �1i3alS� <br />�jr �0.1�'��\1��' <br />AsSIGNEDTO: MI1�r� <br />Tracy <br />9s3�� <br />Street Number <br />Dir ion S at ame <br />P 1 E:a3G9 <br />C <br />Ti Code <br />HOME or MAILING ADDRESS (H Different front Site Address) <br />3 <br />Payment Type�� <br />Street Number <br />§trectNarne <br />CITY <br />Received By: <br />STATE ZIP <br />PHONE #1ExT. APN # <br />Sia- S.'73 <br />LAND USE APPLICATION # <br />001) <br />PHONE #2 ExT. <br />( 1 <br />BIDS DISTRICT <br />LOCATION CODE <br />rnvTR ACTnR / SF.RVICE REOUESTUR <br />REQUESTOR /-t u OL5 1 � e G -an c J„ •eZ <br />`✓' ` <br />CwcK If BILUmo ADDRESS <br />BUSINESS NAME �, t,�0.14 Q�J <br />S.�" eN, CSC —'Y� <br />PHONE ct p C E <br />O� <br />HOME Or MAILING ADDRESS /' ! �D <br />7 H-I,r3-rs�trc t2� <br />FAX# <br />(�� SYS-- g'9'S3 <br />/r'�� <br />CITY l� /� ��-� <br />$TAT£ ZIP �/G 3 6.1 . �% <br />dLTH <br />BILLING ACKNONALEDGEME\'I: I, the undersigned property or business owber, operator or autnorizea agent of same, <br />acknowledge that ail 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 'orrr.. <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 FGDER.AL laws. <br />APPLICANT'S SIGNATURE: DATE: le) p — / g—/q <br />/l�, ,_p,,� <br />PROPERTY 1 BUSINESS OWNER❑ OPERATOR / .MANAGER El OTHER AUTHORIZED AGENT l OVon-4k C - y 1 <br />U-APPLICART is not the BILLING PART)', 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 environtneDtallsite assessment <br />information to the SAN JOAQUIN COUNTY EwPONNtENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my represe�nitative. 1 y� <br />Ir- n- Ctes-VCI,IICCTCfl• RJ 11 -k/ . a —k - e% l9 1/ �n,w �, 11/.r �]f�I l`I17 hu 1-�APVCLIY <br />COMMENTS:_ �Jt t5f,1 <br />t <br />REC [V'E <br />AUG 13 Z <br />SA -N .IOAOUIN COU <br />HE.ALT}IEhMRp�TM� <br />ACCEPTED BY: �� ��L` <br />EMPLOYEE #: Li 17 Q) <br />Ti <br />DATE: � 3 <br />AsSIGNEDTO: MI1�r� <br />ENWLOYEE#: G, <br />DATE: /a3 <br />Date Service Completed (ii already comp) d): <br />SERVICES CODE: <br />P 1 E:a3G9 <br />Fee Amount: <br />Amount Pai <br />316 vD Payment Date <br />3 <br />Payment Type�� <br />Invoice <br />6.,t� 072 /o <br />Received By: <br />EHD 48-02-025 <br />REVISED 11117;2003 <br />SR FORM (GuddenRD1 IA <br />\cc&, <br />£'d £9689V860Z wnelOa}ed elge11e2l eL17:90 b6 £6 6nV <br />