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SAN JOAQU*OUNTY ENVIRONMENTAL HEALTH 1-PARTMENT <br />SERVICE REQUEST <br />Type Aof�Business or <br />f/T'r�li Property <br />4 mi tJ <br />FACILITY ID# <br />//- i <br />FN <br />� <br />PHANE ^� ExT. <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />�i4 <br />Jj� <br />�` &46&IfBILUNGADDRESS� <br />STATE / ZIP 7t~ <br />„� t� - <br />t,? �- J =,%,%js� � <br />iL <br />EMPLOYEE #: 1/ $ <br />FACILITY NAME <br />I/ J I.3 I (, <br />ASSIGNED TO: �%.1- � - Tun ell -/ � <br />EMPLOYEE #: r/li, Q. <br />DATE: <br />q113 14 <br />Date Service Completed (if already completed): t{/ �' 6 <br />SERVICE CODE: 3� D <br />SITE ADDRESS { o / �-/,�1 <br />�j 7 <br />j� <br />/. { <br />Payment Date 16 <br />r G71r 1� <br />W.231, <br />Stre7et Number <br />Dire"coon(/ <br />Street Name <br />it <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address)14-� <br />C <br />Street Nunber <br />Street Name <br />CITY r k <br />$TATE <br />ZIPS <br />PHONE #1 <br />(209) 0k& <br />ExT. <br />APN # <br />LAND USE APPLICATION # <br />UP -W -S 4 UP ,qs 1 <br />PHONE #2 <br />( } <br />EXT. <br />BOS DISTRICT <br />t.r -/ <br />11 <br />LOCATION CODE <br />l <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORe �T Y (P�q,,._ <br />t � <br />CHECK if BILLING ADDRESS <br />y <br />BUSINESS NAME <br />FN <br />� <br />PHANE ^� ExT. <br />HOME or MAILING ADDRESSFAX <br />'17,� ss �, <br />4�/s - � C, k -1 . - 114 .�-.� <br />4Y /l - Ck - i' f _ A -S _ /_ ��, Y 6,121- Ck - 1-7 -S! � <br /># <br />(M) 3G <br />CITY ® <br />STATE / ZIP 7t~ <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 HEALTtt 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 thisW,*Ds <br />the work to be perfonned will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, StandardL laws. <br />APPLICANT'S SIGNATURE: -g9AV DATE: <br />PROPERTY/BusINESSOwNER❑ t ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br />ffAPPL1C:aNT is not the BILLING P.,tRTY. proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 HEALTEi DEPARTMENT as soon as it is available and at the sarne time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: V �' 1 v t 4�►' ee �ir�' - �{ d'�-` <br />COMMENTS: ll e ff <br />FN <br />� <br />61a - Die 6x, �� �� -'t-S t �p <br />-5-AyFNF� <br />�p <br />4�/s - � C, k -1 . - 114 .�-.� <br />4Y /l - Ck - i' f _ A -S _ /_ ��, Y 6,121- Ck - 1-7 -S! � <br />R fc� <br />S"'1 13 <br />6/17 - CX- r 7 - tiS .- f l 1 `�s1 - 6 X - /6, 6 �_ / - �%'`� - <br />hE� ()kk c , <br />6 zo_ 6 k- t'!- -,,zA T <br />ti <br />ACCEPTED BY: 03 <br />EMPLOYEE #: 1/ $ <br />DATE: <br />I/ J I.3 I (, <br />ASSIGNED TO: �%.1- � - Tun ell -/ � <br />EMPLOYEE #: r/li, Q. <br />DATE: <br />q113 14 <br />Date Service Completed (if already completed): t{/ �' 6 <br />SERVICE CODE: 3� D <br />P I E: 'I YO <br />Fee Amount: 1 "� <br />Amount Pat 3�D v� <br />Payment Date 16 <br />Payment Type <br />invoice # <br />Ch # O <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />