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SAN JOAQUIN COUNTY ENVIRONMENTAL. HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ellasE"v ellow>rl4C <br />FACILITY ID # <br />—,0094 f -- OO 5 <br />SERVICE REQUEST # <br />OWNER /Q <br />�t�' -� ���%[I�I/✓ CQ�/t// / � /- ��weClr% i��/`-! ,�/G �/ "'S'IfZJ�CHD,�S <br />�✓ <br />` 40V <br />FACILITY NAME /;!�TI` ,A?4 17W� /� �g�?./ / w /,1�.�/G <br />TOD7.R,0W--1 <br />SITEADDRESS -?//3o <br />Street Number <br />Direction <br />/*7—e—VV!'TN ,I� <br />Street Name <br />953 77 <br />I Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY G / �,.,. / STATE e -If ZIP ®S 1O c <br />e` V 7 ...7 <br />PHONE #1 ExT- <br />(. uO) I/6t -70'96 <br />APN # <br />25303010 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / Se REQUESTOR <br />REQUESTORg/CL �,•,��v �, L <br />`✓ <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME-'4wB u/� C NS �, �jA —_<0'21D <br />PHONE# <br />�b <br />Hr er MAILING /ADDRESS <br />/9. ® rte- s <br />�7 / <br />("®Q/) <br />/� �. �g®• <br />�r�—y <br />CZIP <br />CITY �� �� /P STATE <br />�7 <br />9- <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE:, ®® DATE:�-�/� r� <br />PROPERTY / BUSINESS OWNER ❑ ' OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT / <br />d `+ l ` e/lo-Ileew IAII <br />If APPLICANT is not the BILLING PARTY 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: <br />COMMENTS: DRM4IAI-f <br />JV -16 69?/"ve; <br />If 9/p7 _ ®. <br />J-2//8 /a7— ®� <br />. <br />ACCEPTED BY: r <br />'� l® %#� <br />ASSIGNED TO: a % c <br />EMPLOYEE #: W90 <br />DATE: `/9/0 7 <br />Date Service Completed (if already completed): `//Z /'7 <br />SERVICE CODE: <br />P 1 E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment TypeInvoice <br /># <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />M <br />