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SAN JOAQUIIIOUNTY ENVIRONMENTAL HEALTLI DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />1 ‘, 7 <br />SERVICE REQUEST # <br />OWNER / OPERATOR CHECK if BILLING ADDRESS <br />FACILITY NAME V . . <br />A ,e,f-c etiatLigt7 <br />) <br />SITE ADDRESS <br />Street Number Direction ‘et Name <br />-,,cieZtet4V7 <br />City <br />q5-,2 -0 7 <br />Zip Code <br />HOME Of MAILING ADDRESS If Different from Site Address) <br />Street Number Street Name - <br />CITY STATE ZIP <br />.. <br />PHONE #.1 EXT. <br />( ) <br />APN # <br />/ c ' < — 2-So —2_S <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT 2_ LOCATION CODE <br />( <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTORiL <br />ddil <br />A 4 <br />( ric/7,41/ <br />CHECK if BILLING ADDRESSES.. <br />BUSINESS NAME I) <br />'/•-aivovi 14.6 9 <br />PHONE # <br />107) <br />EXT. <br />HOME or MAILINF ADWESS <br />rOA&A" 742 <br />FAX # <br />CITY Wit5)000(4//ij‘ <br />STATE c4. zip,75-- <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 DERAL laws. <br />,.........--t-- DATE: 5-- - 7D e. <br />PROPERTY / BUSINESS OWN OPERATOR / MANAGER OTHER OTHER AUTHORIZED AGENT 0 <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 DE/ARTMENT as soon as it is available and at the same time it is <br />r,rovidpd In me or my ntative. ob 12-,F24( d- Jog-4 C-A-'0 . _ <br />TYPE OF SERVICE REQUESTED: V4 8 `I• 1143 10 <br />Ell oiscARD <br />COMMENTS: <br /> <br />IV D <br />MAY <br />sANJo AQ i i 2010 <br />,,,Ervv,,,,k/N couN <br />---41-71-i DEZVTAL 71( <br />ACCEPTED BY: 1,7ated44410C EMPLOYEE #: b:90 DATE: <br />ASSIGNED TO: i <br />EMPLOYEE #: 6, .943 DATE: Vii /0 <br />Date Service Completed (if already completed): SERVICE CODE: () 3,-.- PIE: <br />Fee Amount: 1 ez...3 0 Ac."-D Amount Paid 0 — Payment Date 6/ ty t O <br />Payment Type i../- Invoice # Check # k 'i'S'L) Received By: <br />APPLICANT'S SIGNATURE: <br />Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003