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SAN JOAQUL —OUNTY ENVIRONMENTAL HEALTH — PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />S a ooz 131-q <br />OWNER! OPERATOR <br />Al o 6( F; Z-k il 0 0 f 1- \ ?---- <br />CHECK if BILLING ADDRESS <br />FACILITY NAME .A) c.) c ( Q I -Lot,. y,.\. 0 0 <br />9 <D7-15 <br />Zip Code <br />SITE ADDRESS <br />cs c? ( 7_ Street Number Direction <br />P\ ct i V\ S k <br />Street Name <br />sk-ocX; --or) <br />City <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />. 1/2 --- ZvictP /y' 6 72 Street Number , Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />() --S S 1 — 6 5 37 <br />APN # I LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />II <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR , c <br />11 <br />, — <br />I 1 ( 141/V) 0 ç\ 'CE <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME , r) , --) <br />-- i M<TS V \ e___CAY\r3 c2 Ck <br />pv),s I 6 ss- 7EXT. <br />HOME or MAILING ADDRESS 05 6 q / y_ E .4 , <br />/qa, \A \- <br />Fax # <br />( ) <br />CITY <br />0 C k \ (fill <br />STATE C A ZIP CI t IS <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 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 FEDERAL laws. <br />I APPLICANT'S SIGNATURE: C f2 .-i, ' "/.,<--;,,y,,,) _../2 DATE: ( —ll — 19 <br />PROPERTY / BUSINESS OWNERI2" OPERATOR / 1V1ANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available anAihe same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: 1--)0C \,) e v\ 1 cke e (x/G\AII/iikA---- -.04„,-icivii, <br />ile t) COMMENTS: <br />kt W-0A/UCC, 'TV C Ait V-- 4 <br />kW <br />/ 8' IN.,, I <br />4-4Qt, 2049 <br />ifeou illi'o N c 7*If 444°44. <br />-747. <br />ACCEPTED BY: \ I . (V Wili\C) EMPLOYEE #: DATE: 11,-1 Li_ (1 <br />ASSIGNED TO: 67) , 41\ r 1 ails" t EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): <br />,___ <br />SERVICE CODE: D(.0 ( PIE(hio5 <br />Fee Amount: ark \ 52_ Amount Paid 4 r Payment Date <br />Payment Type V[6:7Z._ Invoice # Check # Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 No)-aqZ66 <br />SR FORM (Golden Rod)