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y - +• <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />Ce446-47 S�9�1//if�R`7 C�✓/�fI <br />FACILITY ID # <br />L 3p -'f/f� — D©S <br />SERVICE REQUEST # <br />L <br />OWNER / GPeMrM <br />CH�CK' BILLINGADDRESS <br />c e/�,/J�G[�� i <br />6�///7/� <br />FACILITY NAME 17W L Ua✓ 6S r <br />G�//3�® <br />SITE ADDRESS <br />Street Number <br />U4%%t"t <br />Direction <br />e-elzew- _ LU�f �� <br />Street Name <br />�IP%f�% <br />City <br />/ �3 %? <br />Zi Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) / elo <br />Street Number <br />��ZLC'L7 6r <br />Street Name <br />CITY Oji �,�, / STATE e d ZIP d �® <br />7 <br />/`- [?C <br />PHONE #1 EXT. <br />('209) f1(,� -- 3� 6 <br />APN # <br />2 53 030 /® <br />LAND USE APPLIIC"IATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR <br />REQUESTOR ` / G �I/PV LL <br />!^' /;I/G � <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME) "if ri/►j� G/�� y— �wl� —rO2 /4 <br />PHONE IN <br />/'/✓so�/�} C L ���y <br />fj�i/7 � (� /�. �?�1�//�v/�//✓� <br />Muer MAILING ADDRESSn. ® r / v <br />/" j� <br />09) <br />2 <br />f �� d ® 7 r/ <br />/" STATE <br />CITY C� ZX 0?t-1 <br />�� <br />ZIP <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 FE RAL laws. <br />APPLICANT'S SIGNATURE: '��� DATEE:�o <br />T Ii(�f _ <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGEN��^ 1 `� e/�1G <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INI.ORMATION: 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: <br />COMMENTS: DpRI CG I/✓l ��� /� �,. / <br />/ ER/�il�i✓�"ii��~� �'RV","f" �D <br />/'/✓so�/�} C L ���y <br />fj�i/7 � (� /�. �?�1�//�v/�//✓� <br />G/r�L�. r <br />ACCEPTED BY: <br />EMPLOYEE #: d <br />DATE: <br />rs! <br />ASSIGNED TO: <br />® <br />EMPLOYEE #: 41$' <br />DATE: <br />119,407 <br />107 <br />Date Service Completed (if already completed): <br />SERVICE CODE:P <br />// E: ll <br />Fee Amount: 7 <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR FORM (Golden Rod) <br />