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EHD 48-02-025 <br />REVISED 11/17/2003 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID if SERVICE REQUEST # <br />OWNER! OPERATOR <br />Jim Boone CHECK if BILLING ADDRESS 5. <br />FACILITY NAME <br />SITE ADDRESS <br />24261 Street Number Direction E. Hwy 4 <br />Street Name Farmington <br />City <br />95230 <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />24261 E. Hwy 4 Street Number Street Name <br />PATAIE <br />RECE11 Civi' <br />Farmington STAT. ua ZIP95230 <br />PHONE #1 Err. <br />(209 )886-5490 <br />APN # <br />187-050-17 <br />APR 0 / LAND USE APPLICATION # <br />SAN jc),A Q u iN c <br />PHONE #2 Err. <br />I ( ) <br />BOS DISTRICT <br />I <br />1-04i/Rt4WFV1E7 PAR <br />I <br />NT <br />ED <br />021 <br />OUNTY <br />TA L <br />MENT <br />REQUESTOR <br />BUSINESS NAME <br />CONTRACTOR / SERVICE REQUESTOR <br />PHONE # <br />CHECK If BILLING ADDRESS El <br />EXT. <br />HOME or MAILING ADDRESS <br />`Id b f HI Li <br />FAx # <br />) <br />STATE ZIP riica. CITY <br />F14 io Jr1 <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 tile 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: 1(er:Li fl INC Ct-n <br /> <br />DATE: Utt ° a( <br />PROPERTY / BUSINESS OWNER'S C OPERAT ( / MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />APPLICANTliS not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />above site address, hereb)il 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: Ve r 1, f 6€ 44 Yl O r .5( p it SY5 4"e VIVI <br />COMMENTS: N ts .c.fspi iz Fowl <br />a tec, whfre cp,9-iz. <br />1,6V VAGIC,i; <br />1 h .6.,, yid 6, si,„,,,,zwe, ptopo6r4 ne vi 5 eme r e4-1,,,,,, r)7,4y bE i v , <br />rnoy be- locetfeet Vey ) ry !bat swi g 5 )(P/ern is i'10 " i l k) 4Y WI afrICI <br />ACCEPTED BY: .---72... EMPLOYEE #: DATE: 3 / / <br />ASSIGNED TO: ill S EMPLOYEE #: DATE: <br />Date Service Completed (If already completed): SERVICE CODE: ..• PIE: <br />Fee Amount: 4- 1 5,— Amount Pait0 /5-0Z OD Payment Date <br />Payment Type djatdi__1, Invoice # Check # /2_27 0/ 6 (.., Received By: <br />Title <br />SR FORM (Golden Rod)