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PROPERTY / BUSINESS OWN <br />APPLICANT'S SIGNATURE: DATE: <br />OTHER AUTHORIZED AGENT 0 <br />SAN JOAQUIN C. !TY ENVIRONMENTAL HEALTH DE1 .TMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER! OPERATOR p a h71 C / -11 -Fick li (In Or z CHECK if BILLING ADDRESS <br />FACILITY NAME L G'il C hei-1 0 ch(v9a/0 , SITE ADDRESS n I —1 <br />Street Number ) Direction (i/h I 01111-- Stree Name <br />iroc0-00 <br />City <br />al2cko <br />Zip Code <br />HOME Or MAILING ADD35SAS (If Different m <br /> <br />_ !ro,Site Address) II -7 Li) • I a /7 /7 6/ /1 ci (}J (1/Street Number Street Name <br />CITY 5, to c k/ _to il STATE c it ZIP I c 2 0G <br />PHONE #1 <br />( 3_ VI) 361 ----52 -11 <br />EXT. APN # LAND USE APPLICATION # <br />PHONE #2 <br />( 2ui J:-.1 1 — 1 ))-2-z <br />EXT. BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR r 6, ty , . 6,, 0 Hr )'h a 1,7 at. z <br />CHECK if BILLING ADDRESS Eie <br />BUSINESS NAME Lorch-eyio Ch(4)901 <br />Trot ) 3,,./ 5 ..... s-2, 7 -7 EXT. <br />HOME or MAILING ADDRESS 1 m -1 Lp Tap-VG/96 0 GU a y FAX # <br />( ) <br />CITY .‘„.5 1-D (J -C) r) STATE e A ZIP of s265 <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 />If APPLICA T Is not the B1L ING PARTY, proof o 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 and alto% time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />46Eirtri.: . <br />' <br />COMMENTS: Ori 2 8 20/9 <br />804^/Jai 4.... <br />QUIN CO liEk72110/vm.A „JAI)), <br />" OZPAR74filiivr <br />ACCEPTED BY: C--'\ c\cl V\ (ikx .1 \ \4\ Q..-1., EMPLOYEE #: DATE: <br />ASSIGNED TO: \i.....(X 4 (\Art \„( Qc EMPLOYEE #: \_.\C‘O\ DATE: <br />Date Service Completed (if already completed): SERVICE CODE: \.,..Q .n PIE. <br />Fee Amount: \C-.31. ou Amount Paid -A, \ 0„.,'"--- <br />, <br />Payment Date ',2 3 H- <br />Payment Type v IA- Invoice # Check # Received By: , <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod)