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.S64
<br />3.951 SAN JOAQUIN _UNTY ENVIRONMENTAL HEALTH DIRRTMENT
<br />SERVICE REQUEST
<br />Type of Business or Property FACILITY ID #
<br />-PC 0003 7]—
<br />SERVICE REQUEST #
<br />2 pogl Loot 2_
<br />OWNER/OPERATOR CHECK if BILLING ADDRESS
<br />,-- FACILITY NAME Apa_ry toe A) r S DA,,, D eiz-e e tic_
<br />SITE ADDRESS
<br />/ 70 / Street Number Direction
<br />, „
<br />1
<br /> t a
<br />5. 00 TVL. V 1 II
<br />Street Name
<br />LC I) I
<br />Cite
<br />95.2q7.-
<br />Zip Code
<br />HOME Or MAILING ADDRESS (If Different from Site Address)
<br />Street Number Street Name
<br />CITY STATE ZIP
<br />PHONE #1 EXT.
<br />(Z°61 ) 1`.( 1'415
<br />APN # LAND USE APPLICATION #
<br />PHONE #2 EXT.
<br />( )
<br />BOS DISTRICT LOCATION CODE
<br />CONTRACTOR / SERVICE REQUESTOR
<br />REQUESTOR ,----P:
<br />/121 -rc_.).) I g Ay& lavc CHECK if BILLING ADDRESS
<br />BUSINESS NAME
<br />l IE# P '
<br />EXT.
<br />HOME or MAILING ADDRESS
<br />0 geo 3 .
<br />FAX #
<br />( )
<br />CITY 60 ; „....) (2, s ,,,J,,, -_•,4 STATE ZIP 93-6/7D
<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 t t the work to be performed will be done in accordance with all SAN JOAQUIN
<br />COUNTY Ordinance Codes, Standard., ST TE and FED AL ws.
<br />APPLICANT'S SIGNATURE: DATE: ZO
<br />PROPERTY / BUSINESS OWNEREI OPERATOR / MANAGER 0 OTHER AUTHORIZED AG EN'pZI 71 0-0 /AA 1JCLF
<br />TYPE OF SERVICE REQUESTED: JAN 3 1
<br />...
<br />204 COMMENTS: .-:-) t...) -e u_.) sni2e., N u0/4Q, ,
<br />lidAtv/1?0 ''''"cou try D itittk-Aq. Nr
<br />-bkr-to -) S c-x-Aok.) 1,3 .t.„,_.) c...op Ads, EPAR 7. At
<br />4447..
<br />l'IC,VJ L:k w,..-k— CAA.) C-01,) GrC -I' C PI b 161-v --r o fi 1 I
<br />ACCEPTED BY: C.,..,c,c, 0,..‘( \--\\NQ..-2.-
<br />I
<br />EMPLOYEE #: DATE: \.3 A.,,,,
<br />ASSIGNED TO: ..... j c) e As‹.-(A-t cA. EMPLOYEE #: DATE:
<br />\-
<br />N•3 \ \ 2_(..)
<br />Date Service Completed (if already completed): SERVICE CODE: „D.-2_..?...) p/ E: .5u2 0,,z,
<br />Fee Amount: Amount Pai0304/.. 00 Payment Date /3/20
<br />,
<br />Payment Type d,r_____
<br />')-')(-i'--V
<br />Invoice # Check # ,s--g,..3 Recei ed By:1-75--
<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/sitAkisympnt
<br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at theftelninsAir
<br />provided to me or my representative.
<br />EHD 48-02-025
<br /> SR FORM (Golden Rod)
<br />REVISED 11/17/2003
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