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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />t�v5er <br />FACILITY ID # <br />SERVICE REQUEST # <br />Tre-tlt,, wL►f teedt+ eY <br />-'4 <br />15RGO84G <br />EXT. <br />L1511– 2G� 0 <br />OWNER/ OPERATOR <br />FAX# <br />(209) <br />f / <br />pl ti41m 1Z 1,✓1vCi'fA-S CLL O�.G' �/!✓�� � S L 44 CHECK If BILLING ADDRESS <br />FACIL NAM <br />ENVIRONMEN <br />STATE et4- <br />SITE ADDRESS <br />/6-31 u <br />HEALTH EPAP. <br />�� p✓n �n <br />440 / <br />Street Number <br />Dlrectlon <br />Street Name <br />EMPLOYEE #: <br />Cit <br />ZI Code <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) 176,5 <br />/� <br />/E: <br />Street Number <br />Street Name <br />CITY 5f LI <br />'rZ} IL <br />STATE e,4 ZIP q <br />Payment Type �� <br />Invoice # <br />J Z <br />PHONE#t ExT• <br />(209) `�9p-2(oSp <br />23 7i <br />APN # <br />025=196-3! <br />LAND USE APPLICATION # <br />l',V7 -3011yo Q.�(z1oo�- <br />`HOaqj ! 13Lf — �r S Ems' <br />BOS DISTRICT 1� <br />—1[ <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR h�IlGrl <br />t�v5er <br />o-,, A,,SIR M <br />CHECK If BILLING ADDRESS® <br />BUSINESS NAME/I <br />Ht kw <br />1 <br />tz�v�s{�c L`L a�C1 ,C., <br />PHONE# <br />(log <br />EXT. <br />L1511– 2G� 0 <br />HOME or MAILING ADDRESS <br />!2113 ld- (f -r114 .SfY�f <br />FAX# <br />(209) <br />L/96 -2LGy <br />CITY —qf'-'r1k4C1 <br />ENVIRONMEN <br />STATE et4- <br />ZIP I/ S^2 O Z <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 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.(�Gurte� t <br />M -%p g,-Aj--Nth 4 &a <br />APPLICANT'S SIGNATURE: I r �rtsc ,c.. DATE: // / <br />PROPERTY/ BUSINESS OWNER OPERATOR / MI ANAGER ❑ OTHERAUTHORIZED AGENT 12r P/'l SiY, IL <br />If APPLIGIN is not the BILLING PARTY, p,'oof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INTORMATION: 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 JOAQurN 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 OFSERVICEREQUESTED: )2Bt1lZJ GviCf ARrble <br />o-,, A,,SIR M <br />COMMENTS: <br />DEC 17 L <br />SAN JOAQUIN C <br />ENVIRONMEN <br />HEALTH EPAP. <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: 1 <br />71d 2,Y <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service dompleted (If already completed): <br />SERVICE CODE: <br />/E: <br />Fee Amount: <br />Amount Paid <br />0 <br />Payment Date <br />Payment Type �� <br />Invoice # <br />C ck # 3 (p <br />23 7i <br />Received By: <br />EHD 48-02-025 12-11(,l 20 L) SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />IT <br />:® <br />)21 <br />,UNTY <br />FAIL <br />MENT <br />