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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property ' FACILITY ID # <br />/P7C0 <br />SERVICE REQUEST # , <br />SRDO S -7 1 3 if' <br />OWNER/OPERATOR CHECK if BILLING ADDRESS II <br />FACILITY NAME ti Li) E crieawrz-- \..) , <br />SITE ADDRESS 6-70 <br />Street Number Direction <br />E: v,r-dos_ ST- <br />Street Name <br />LODE_ <br />City <br />V6;2 LID <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # <br />047 - 3 90—t 6 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( / <br />BOS DISTRICT if LOCATION CODE <br />2— <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />1---Ek X) S17/01)C41/ sv e. CHECK if BILLING ADDRESS LT. <br />( \ <br />f;ILD EA) 67PTE fre)(-1— BUSINESS NAME . <br />P_PA-a_ZS <br />EXT <br />PIA 473 -7 -24 <br />HOME or MAILING ADDRESS <br />Po box 03a I <br />Fax # <br />( ) <br />Cny .Ipt CiI0 STATE 6, 4 ZIP Cl 5024 <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 i y business as identified on this form. <br />cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />E and FE'L laws. <br />VWO APPLICANT'S SIGNATU II °/, <br />ar <br />, 4 - c " <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT a ,I2n2._ ,sre-ciie w <br />If APPLICANT is 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, 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: p Fr s-,, en,4-c.--7-7( Ac...,,cea „aez _ A....w...) c-ye ..c..c.c._ F NT <br />COMMENTS: RECEIVED <br />JUL 1 7 2909 <br />sp,N JoActuiN ce,r ENVIRONME _ ._ <br />HEALTH DEPART MtN <br />ACCEPTED BY: C)C_L t.../ se-Cie.,4- EMPLOYEE #: 0 2-24 DATE: 7//77.0 9 <br />ASSIGNED TO: e‘.4.e..44 2.-"+" EMPLOYEE #: 40 ,242 DATE: 7/177,01 <br />Date Service Completed (if already completed): SERVICE CODE: ,5- PiE: 34,0a_ <br />Fee Amount: 1 ..9 € 0 . 0-0 Amount Paid 1210, CD Payment Date 71iii a cfp <br />Payment Type L......, Invoice # Check # .2...6ai Received By: il <br />I also certify that I have prepare <br />COUNTY Ordinance Codes, Sta <br />DATE: <br />Title <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod)