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RECEIVED <br /> FEB 0 S 2011 <br /> ENVIRONMENTAL HEALTH SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> PE MIT SERVICES SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> it I r 2,a 5/?z I ( ItIq <br /> OWNER/OPERATOR - <br /> CHECK H BILLING ADORaSS <br /> FAOIUTY NAME ]� 0 a <br /> JJ <br /> SITEADDRESS ',f" / 1 /p <br /> beat Number Direction Ur r St tName ry k C, 9. a <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> slreal Number Street Neme <br /> CITY <br /> STATE ZIP <br /> PHONE41 Ex*. APN p LAND USE APPLICATION# <br /> l I <br /> PRONE#2 EXT. SOS OMTRICT LOCATION CODE <br /> I ) , <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REgUESTOR �j-/� / <br /> CHECK If BALLING ADDRessE] <br /> BUSINESS NAME / P �� Eat <br /> --fbol MA Ct Z19 <br /> HOME Of MOLING ADDRESS ( F <br /> CITYyk� r I I Jp s�O <br /> STATE zip 5 <br /> n It <br /> BILLING ACKNOWLEDGEMENT; 1, 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 /> 1 also certify that 1 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: <br /> rI—�I DATE: <br /> ikOP1N I'i'i Hl;sl�Eaa DWNERI� � DPFRATOR/MANAGER C] OTNEa AIi'f1iDRIQ1:D AG&`rr wT� <br /> /f APPLICANT is t,ot 1 "Bl NG PARTY proof ajouthorizatlon to sign is required Title" f nqf r <br /> AUTHORIZATION TO RE EASE 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 assessme <br /> n <br /> information to the SAN JOAQUIN COUNTY ENVIRDNMFNTAI,HEALTii DF.PARTMIENT 85 soon 85 it is available and at the same time it is <br /> t z <br /> provided to"It or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> i1Ate <br /> ,, on f1y <br /> ,y. <br /> EQUESTED: VG�� <br /> I� reep r (94 yward hlr�x0cw j�vs <br /> W% Po ywltcrd ?-S2-000 Eg 9 201 <br /> \ 111N C IAL <br /> ACCEPTED Byt �J SA EN COMER M <br /> EIMPLOYEE#: nATc. +� <br /> AaSIGNED TO: _p <br /> l EMPLOYEE#: DATE <br /> Date Service Completed Ilf already complatedi, <br /> SERVICE:DDE: <br /> Fee Amount: . 2 °' Amount Paid <br /> PaymentT a Payment Date <br /> Yp Wu C S Invoice# 6heeRS <br /> Receive <br /> fHD 48.02.025 C } D 5 b (7 <br /> REVISED 71/17/2003 SR FORM(Golden Rod) <br /> 21T:a69d 82T0b9b602T:O1 0bTT)-9S9TG 06TTL999T6:WO.t3 26:f7T T102-80-83d <br />