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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> / G � o o v* \V 1 4 6 y r L C CHECK H BILLING ADDRESS 0 <br /> ` 1 <br /> FACILITY NAME L o w e15 C o S koVc S 1 C)f C i l if Z�-3 <br /> SITE ADDRESS CG�01f� E—(J�� <br /> Street Number I Direction ktreet Name <br /> HOME MAILING <br /> MAILING ADDRESS (if Different from Site Address) <br /> S - 0 , Q '` D-,6'L)—L C) Street Number Street Name <br /> CITY rt 1(A� 0 C i l SFT,E zip(�b <br /> PHONE#1 \ Exr.I APN# LAND USE APPLICATION# <br /> 0105) 60 G0 2:453Qi ()al <br /> PHONE#2 Err. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR S S2 LJLJ <br /> �� CHECK if BILLING ADDRESS <br /> BUSINESS NAMEExT <br /> ) C)V IS Car}V♦ S V L J d-P C PHONE# Q p^ ' O r <br /> HOME Or MAILING, 0ADD C1 O ( Lia,) (J / <br /> CITY O ' C)--,\&t C 1 �—\ STATES K\ zI"'? <br /> BILLING ACKNOWLEDGEMENT: I, the ndersigned property or business owner, operator <br /> 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 SIGNATURE: ::�2 DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER br— OTHER AUTHORIZED AGENT❑ �^J 1 "1 �S�/� <br /> IfAPPGICANT 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/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 SOO it is available and at the same time it is <br /> provided to me or my representative. mom IP' <br /> TYPE OF S�RVIC S� v <br /> COMMENTS:' RECEIVED <br /> AUG 2ZZ017 <br /> AUG 2 3 20V <br /> 1 SAN JOAOUtN COUNTY <br /> EWRONMENTAL ENVIRONMENTAL HEALT <br /> HEALTH DEPARTMENT - NT <br /> ACCEPTED BY: <br /> EMPLOYEE#: DATE: -d p <br /> ASSIGNED TO: EMPLOYEE#: V DATE: t� I <br /> Date Service Completed (if already completed): SERVICES CODE: Y P I E: a 3 <br /> Fee Amount: Amount Pal �Sca i](� Payment Date F / 7 <br /> Payment Type Invoice# Check# ��i g�ze�S Received By: <br /> dIN– <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />