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SAN JOAQUIN COUNTY ENVIRONNIENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />/ Prj1!%f f(j�}� /7jt 5 <br />l r• ` <br />YpMCM19C%S 0 <br />FACILITY ID # <br />BUSINESS NAMEPHONE <br />Nu2R�Y ¢�LbwA�s R'f/t <br />SERVICE REQUEST # <br />NIGH SCC-Oot- <br />14 <br />HOME or MAILING ADDRESS <br />3c7'ZS 5v47�A#ILAP-da-To <br />r <br />C2G— (�f3 <br />CITY ` of 2L/(0-6 <br />STATE /A <br />ZIP -7 <br />ACCEPTED BY: <br />OWNER I OPERATOR <br />/ OT / C)S D <br />CCII <br />CHECK If BILLING ADDRESS <br />FACILITY NAME ^ - q. <br />/ /a G C <br />CiC <br />(�� SG06O <br />SITE ADDRESS /O sS5 <br />��R&M� RD • <br />G KTDN L ZOO{ <br />Street Number Direction <br />Street Name <br />cityZi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 3 O S' <br />', <br />' / <br />t7 STS' ET <br />Amount Paid �3� 0 r <br />Street Numher <br />{ t El p <br />Street Name <br />CITY / O I <br />L <br />�J <br />STATE ZIP C1S Z9 0 <br />L <br />PHONE #1 EKT' <br />(M) 3-3/ - S078 <br />APN # <br />066 - OZ -0 -o-i <br />LAND USE APPLICATION # <br />PHONE #2 Exr• <br />7/Z'I3 <br />BOS DISTRICT <br />LOCATION CODE <br />(zoi) <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORD�)AJS 'thA <br />TILL <br />/ Prj1!%f f(j�}� /7jt 5 <br />l r• ` <br />YpMCM19C%S 0 <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEPHONE <br />Nu2R�Y ¢�LbwA�s R'f/t <br />fi2�lftTEcT 5 <br />#T' <br />14 <br />HOME or MAILING ADDRESS <br />3c7'ZS 5v47�A#ILAP-da-To <br />FAx # <br />(5`Jo) <br />C2G— (�f3 <br />CITY ` of 2L/(0-6 <br />STATE /A <br />ZIP -7 <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 or <br />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. c/ <br />APPLICANT'S SIGNATURE: DATE: ' 1 / 7 Zoo 7 <br />PROPERTY / BUSINESS OWNER❑ OPERATOR / MANAGER OTHER AUTHORIZED AGENT, /PROD'. <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 />A.)EcU Sc v/ A--( t—( / /--16; P©a L t `�I MSN <br />COMMENTS: <br />i-�ECE <br />ApR 1 8 2007 <br />SAN JOAOUIN COUNTY <br />EALTHODFPA TMENT <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: Q <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: s%/ <br />P / E: O <br />Fee Amount:It ?J$"p <br />`S <br />Amount Paid �3� 0 r <br />Payment Date <br />{ t El p <br />Payment Type �, <br />Invoice # <br />Check # [ �'3 S3 <br />Received By: Ze <br />EHD 48-02-025 ' .SR FORM (Golden'Rod) <br />REVISED 11/17/2003 <br />