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2 <br />SAN JOAQ OUNTY ENVIRONMErA: 1 T PAATMWNT <br />SERVICE REOUEST <br />Type of Business or Property <br />FACILITY ID # <br />COMMENTS: <br />SERVICE <br />�osPr('PL /hlfAL1 rJ Ga(Z.E <br />AUG <br />�5i.©v <br />OWNER I OPERATOR 1 <br />` <br />�AIsc L PEMMA.4E,N r E, <br />CHECK if <br />BILLING ADDRESS❑ <br />FACILITY NAME K,A ISE � PE 2MA e. <br />DATE: <br />SITE ADDRESS —+—+- , <br />►. ! <br />OSE M ITE A V G <br />ASSIGNED TO: <br />IKAI�EG A <br />EMPLOYEE#: <br />q S33Lo <br />StreetNumber <br />Diirreotion <br />Street Name <br />PIE: J <br />C' <br />Amount Paid <br />Zi Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Payment Type ✓ <br />Invoice # <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT. <br />� O <br />�� �Z S • � -+00 <br />APN # <br />LAND USE APPLICATION # <br />PHOO,NE R Ext. <br />(20 ,) O ?-S � ,� +00 <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />SG61i GovF.y <br />BUSINESS NAME PSlIZo A 14 A LY'P I G6 (. <br />HOME or MAILING ADDRESS <br />Q 0 • c3ox 7-50 <br />CITY © � l tJ � A <br />REQUEST # <br />CHECK if BILLING ADDRESS <br />PHONE# �T• <br />9S 1) SZZ • SI l C) <br />FAX # <br />(951) US-+. 099 1 <br />STATE CA ZIP gt1SlP'3 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of samiA <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 thelo to be performed will be done in accordance with all SAN JoAQ <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL la <br />APPLICANT'S SIGNATURE: DATE: -+ba os <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ DTHEIIAUTHOREM)AGENT PY.AS6cfi' MA0A&VZ <br />IfAPPLICANT is not the BILLING PARTY proof of aWho Ization 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 at the same time it is <br />provided to me or my representative. —IT <br />TYPE OF SERVICE REQUESTED: U <br />CE�v E <br />COMMENTS: <br />4 2005 <br />AUG <br />OulAv <br />SAN �OAQ NN�ENT � T <br />pEPARTMEN <br />ENV►R <br />H�pLTH <br />ACCEPTED BY: <br />EMPLOYEE M 3 <br />DATE: <br />U <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: -- <br />Date Service Completed (if already completed): <br />SERVICE CODE: GJ �i <br />0 <br />PIE: J <br />Fee Amount: <br />Amount Paid <br />�, cI _ <br />Payment Date/ "— <br />Payment Type ✓ <br />Invoice # <br />Check # o6-2- <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED II/17/2003 JUL 2 12005 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />4 <br />