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s � <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />, / ^ <br />1'r G 1 (J ry <br />FACILITY ID # <br />BUSINESS NAME `-r" <br />V" <br />SERVICE REQUEST # <br />2erA,IL P70E- L- <br />PHONE # ExT. <br />(G(Q <br />� 2008 <br />005330 <br />OWNER/ OPERATOR <br />T. <br />HOME or MAILING ADDRESS <br />P. <br />O <br />'nA A� '/ t <br />QV l K- S -�--0 Y V `TIC- 1�-- �7 , .%� e <br />_ <br />CHECK if BILLING ADDRESS <br />FACILITY NAME Q o (I& S ro p .�1 } 6 <br />STATE (7 a ZIP G, 6 4 <br />ACCEPTED BY: C) L I V <br />SITE ADDRESS <br />S <br />© L t V E- <br />A. U Er _ <br />STO C!C "1.4 <br />9 S 2 ( S <br />103 O <br />SERVICE CODE: .199 <br />P / E: )Z'�� poi <br />Fee Amount: Lo L� 0-o <br />Amount Paid (,� <br />I <br />Street Number <br />Direction <br />Street Name <br />Invoice # <br />Ci <br />Zi Code <br />HOME or MAILINGADDRESSADDRE�SyS (If Different from Site Address) <br />�j► Lfi C�✓R. P I L C S 1� S T <br />S <br />T <br />Street Number <br />Street Name <br />CITY 'F(Z, C- a�� <br />L <br />STATE C A ZIP <br />7 <br />PHONE #1 Exr. <br />APN # <br />LAND USE APPLICATION# <br />(T-10 <br />(slo ) 6 s`3 - g S -o O <br />1•57-7 - <br />Z bLt-2 Z <br />PHONE #2 Err. <br />BOS DISTRICT <br />LOCATION CODE <br />Y <br />i <br />f <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR I C 0 Ar& -t, -r <br />, / ^ <br />1'r G 1 (J ry <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME `-r" <br />V" <br />�� �.1 p(,(��21/C(.�, <br />L.,Q. r <br />PHONE # ExT. <br />� 2008 <br />lb 3�3-llrz. <br />HOME or MAILING ADDRESS <br />P. <br />BD X tC) r <br />FAX # <br />(9!(„ ) 31-3 -(t3 <br />CITY - S: X-C"ry <br />STATE (7 a ZIP G, 6 4 <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 EDERAL laws. <br />APPLICANT'S SIGNATURE:/ <br />DATE' <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT R3 C ® wT_IZ. A4--1-0 rL— <br />IfAPPLICANT is not the BILLING PARTY. proof of authorization to sign is requiredTitle�3 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the �f If D <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or enviro to t e <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. FEB - 5 2008 <br />TYPE OF SERVICE REQUESTED: @ <br />E V L Fr'w Y"e S P &4- S <br />CNV <br />JP <br />COMMENTS: <br />� 2008 <br />FEB <br />SAN JOACIIJIN COON <br />RTME <br />ENVIFIONM <br />ACCEPTED BY: C) L I V <br />EMPLOYEE #:1711 <br />L <br />d 3 '2-/ <br />DATE: 11 0 !L <br />ASSIGNED TO: 1°> G <br />EMPLOYEE #: 4%3 G <br />DATE: -5 0 (7 <br />Date Service Completed (if already completed): <br />SERVICE CODE: .199 <br />P / E: )Z'�� poi <br />Fee Amount: Lo L� 0-o <br />Amount Paid (,� <br />I <br />Payment Date <br />I S 16 q <br />Payment Type <br />Invoice # <br />Check # g Zt-1I <br />I Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />