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• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />V t 1 A, L O <br />FACILITY ID # <br />SERVICE REQUEST # <br />F—: FL t\ t C <br />PHONE# EXT' <br />16 3_t - 18�Q IIs <br />HOME or MAILING ADDRESS p <br />TZ E,r N I L � O E- L <br />FAX # <br />z— <br />s Rests -j I g 41 <br />OWNER / OPERATOR <br />SAN JOAQUIN COUNTY <br />.p A,L • 3 t J� tk(` `C <br />�1 <br />p`, <br />CHECK If BILLING ADDRESS <br />FACILITY NAME I R m �f <br />Y14 F,- em PIZ I S e- s <br />Y �'( <br />DATE: <br />SITE ADDRESS <br />s, <br />!� 'D 0P- A,'D o <br />S 'f- - <br />S ro CK -t-()N <br />c1 r 2 0 <br />I <br />16 05 Street Number <br />Direction <br />Street Name <br />PIE: Z -6 <br />city <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Date <br />FC 0 r4 A � Ar h( L � J� I_ <br />3 S S 8 ` Street Number <br />Street Name <br />CITY �2 W 0 ` 7 <br />STATE CAZIP G q 6 <br />7 <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION #7 <br />fSrO) SSZ.' ��LL <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR /^^ I C;4 X li c <br />V t 1 A, L O <br />CHECK if BILLING ADDRESS 12 <br />BUSINESS NAME (il%' <br />F—: FL t\ t C <br />PHONE# EXT' <br />16 3_t - 18�Q IIs <br />HOME or MAILING ADDRESS p <br />O ✓ 0 Z S— <br />FAX # <br />z— <br />CITY vi e -S T- c 2Ar 0A e—L--Iry <br />STATE C A ZIP 9 S-6 t <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 t the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FED RAL laws. <br />APPLICANT'S SIGNATURE: DATE: /Z L Z O 3- <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT V % Q -L- jZ- A-� /L <br />If APPLICANT is not the BILLINGPAR71s 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 and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: [ A t.l 2 e <br />V b 15W e <br />�� L1 RV/ a ,D <br />COMMENTS: <br />SEP 0 5 2007 <br />SEP5 2007 <br />; <br />,��, <br />F_[dVIR t; ;r,;1cPd1- FiEALI ti <br />SAN JOAQUIN COUNTY <br />PERF IMSERVICES <br />ACCEPTED BY: <br />EMP,T <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: v �� <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Q <br />PIE: Z -6 <br />Fee Amount: 2 W4 <br />Amount Paid aq J <br />Paymeni <br />Date <br />Payment Type <br />Invoice # <br />Check # "0- <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />