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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />/ / e----:, - <br />SERVICE REQUEST # i <br />`3F\ c 7 (rci -1 LI- <br />OWNER! OPERATOR --i^ P 1 Irt't C,t C't r CHECK If <-- /4-Pcr rf • i'vl--e igf -S JS ILLING ADDREZS <br />FACILITY NAME <br />SITE ADCRESS <br />2. 00 Street Number <br />/17 <br />DirectIon <br />-17-r-tC1 B I vd . <br />treat Name <br />I rct. 0' <br />Oily <br />'S <br />Zit) oode <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street, Number Street Name <br />CITY STATE ZIP <br />PHoNE #1 EXT. <br />( ) <br />APN # LAM) USE APPLICATION # <br />PHONE 02 EXT. <br />( ) <br />BOS niSTRICT LOCATKN CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR al <br />Itibk-Art ft. sr Pod Pigsf-er,rily <br />BUSINESS NAIVE <br />CHECK If B[L.Li NG AD DRESS12" <br />PHONE # EXT. <br />HOME or or MAILING ADDRESS , <br />000 At r (Z) illtt j e Ri4 _ <br />PAX # <br />( ) <br />..CITY F., T pc9 jr1 . -- STATE C/4- ZIP ? 5 <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 />COUNT'Y Ordinance Codes, Standards, TATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: —/ <br />PROITRTY / BusENESs OWNERD OPERATOR/ MANAGER 0 0-01ER AUTDORIZED AcENT.tile <br />If APPLICANT is not theBILLIWO PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION vsz Ragkg ijsvgpx.A.miN: 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 DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. Y <br />TYPE OF SERVICE REQUESTED: P-O--0 A,144,--7Jed <br />77 -c •=kr Iveo <br />COMMENTS: I VA R , <br />s,AN Jo '120,7 <br />ftek4QL,,,,:, "1€4].N oc)",4r6w;?uArTy ep07,4447. <br />ACCEPTED BY: EMPLOYEE #: Li 3 DATE: ( i 7 7 <br />ASSIGNED TO: EMPLOYEE #: , ; --) . , _\ DATE: 3 i <br />rvicO Comp ,ted (if already completed): SERVICE CODE: ,---- , , Dat e Se m P E: <br />, Payment Date Fee Amount: 77 , 0-0 Amount Pal , 4.)„,.?7,.9d , _1, f) , <br />3// 7 /2 7 <br />Payment Typo invoice # Che,l(ft c_64,—/. -1- 6,54/,..z) Received By: 77,7 <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003