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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAME <br />,FFG -75460,4 FODO COMPAfuyt <br />FACILITY ID # <br />SERVICE REQUEST # <br />f -001D TIGER <br />'2,163 Pun, C ICLc t,r <br />( ) <br />CITY l 61---00&) STATE C4' ZIP 9.r2o <br />OWNER/O//P-11P�IERATOR <br />Z,. s(d <br />{ ,i J- t-aa�lo Ah',ILI/I�i <br />CHECK If BILLING ADDRESS <br />FACILITY NAME L�(� p `_ CAOA F-OOn &� DAN 11 <br />:/ <br />SITE ADDRESS <br />ZZ3S�1 <br />M6'rr L4rn% <br />I <br />4VC <br />myw,4-ao <br />9ySAI <br />Street Number <br />Direction <br />Street <br />Name <br />city <br />Zip Code <br />HOME or MAILING;LtRESS (If Different from Site Address) <br />2 ��L <br />Street Number <br />Street Name <br />C7"MC k7�N <br />Zip <br />C� STATE .fZo�i <br />PHONE #1 E"r• <br />APN # <br />LAND USE APPLICATION # <br />Q'o19V-&-'wo <br />PHONE #2 EM• <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ^ <br />DARPyn/ J. CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />,FFG -75460,4 FODO COMPAfuyt <br />PHONE# En. <br />) <br />HOME Or MAILING DDRESS <br />PAX# <br />'2,163 Pun, C ICLc t,r <br />( ) <br />CITY l 61---00&) STATE C4' ZIP 9.r2o <br />BILLING ACKNOWLEDGEMENT: I, the undersignedproperty 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.? <br />APPLICANT'S SIGNATSIGNATURE: (�)7+ 4c� DATE: 10 • 1 D <br />PROPERTY/ BUSINESS OWNE4EF OPERA / MWkGER ❑ OTHER AUTHORIZED AGENT E3 <br />If APPLICANT is not the B/LLLva 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/i4 assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the M' rka <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: ?[X41 cv ' a cw..f 02'2 <br />' C , e ROU/N COUN <br />��LIIi DE VEN -r <br />AL <br />NT <br />ACCEPTED BY: EMPLOYEE #: (•p -2 /_J DATE: (r( 10 2 Z <br />ASSIGNED TO: �¢ t EMPLOYEE #: DATE: lt) / � 7 <br />Date Service Completed (if already completed): SERVICE CODE: P / E, �0 <br />/_ b!�— <br />Fee Amount: b 8 1 Amount Paid q/og00 Payment Date I01612,2- <br />Payment Type d,() it Invoice # Check # 15-11 `F bl 7 Recei ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />