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11/10/2005 08:24 2094683 EHD PAGE 02 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # SERVICE REQUEST 0 <br />-vi'Ce, -5 Q iOn <br />0D03gr0 <br />5200 4fL02( <br />OWNER OPERATORr f <br />s CHEGC if &CLING ADDRESS ❑ <br />//J <br />I©� <br />ACCEPTED BY: L <br />FACILITY NAME M <br />EMPLOYEE #:- <br />SrrEARDRESS 7501 <br />ASSIGNED TO -.V <br />% ^' _ i/ <br />EMPLOYEE fi: 3 g'� <br />DATE: / 21 <br />Street Number <br />Direction <br />Street Name <br />city Zip coda <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Payment Type <br />Invoice # <br />Check#I D�3 <br />Street Number <br />ftent <br />r.IiY <br />STATE zip <br />Now I1�T <br />czail 838-397/ <br />APN # <br />Ll!ND U3E A>�wacATlo�a # <br />PHONE #2 Exr. <br />1 ) <br />BOS DISTNCT <br />LOCATION Coop <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR _DOy)I <br />CHECK if 131L.I,IN_C, ADoliE9SILY <br />BUSINESS NAME <br />p1i0NEl; E7R. <br />- 39 <br />Home iWu <br />or uwc ADDRESS222-5 I road ven u � <br />( 209) 5 57- 93Q k <br />CCTVCeres STATE (2A <br />ZIP n530 <br />BILLING ACKNOWLEIDG1El1 IE I: I, the undersigned property or business owner, operator or authorized agent of some, <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 YOAQUIN <br />COUNTY Ordinance Codes, Standards rATE and F E AL laws. <br />APPLICAN'T'S SIGNATURE: DATE, i � L <br />PROPERTY / BUSINESS OWNER ❑ TOR / MANACTyR 13 OTHER AUTHORIZED AGENT O Mdm (ri. A -s-,+. <br />1 <br />1fAPPL/C4NT iS not the .&LL1JVG PARTY. proof of authorization to sigh is required Title <br />AIr" FIIOR.IZATION 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 availaablleeYf_ tarld„at t�same time it is <br />provided to me or my representative. � <br />..r 1% 1Cm <br />TYPE OF SERVICE REQUESTED; <br />r/ 7— <br />COMMENTS: <br />Nov 2 1 <br />SAN <br />EJOAQUIN NVIRONMENTAL <br />NVVIRONMENTAL <br />1.IEALTH DEPARTMENT <br />ACCEPTED BY: L <br />EMPLOYEE #:- <br />DATE: <br />ASSIGNED TO -.V <br />% ^' _ i/ <br />EMPLOYEE fi: 3 g'� <br />DATE: / 21 <br />Date Service Completed (if already cAeuL— <br />noleted): <br />SERVICE CODE: <br />PIE: <br />�30p <br />Fee Amount: -�7q p D <br />Amount Paid <br />a 0 D Payment Date I It c <br />Payment Type <br />Invoice # <br />Check#I D�3 <br />Received By. <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2043 <br />