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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 I OPERATOR CHECK if BILLING MDRESS❑ <br /> 7- I-C I-VF--,g -VuC <br /> FACILITY NAME F L E V E M ,/I <br /> SITE ADDRESS C o u kv�-I'L C t 06 S`i`4 C 14 T-C nl 9 5-2 0 11 <br /> -Z -4 Z Street Number Direction 1 Street Name �; CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> '50 Street Number Street Name <br /> CITYSTATE �X ZIP S Z Z <br /> LL4, <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> (% ) I2 i - ; C' -- C' <br /> PHONE N EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR ISA I C N A�L ,i/1/A f is-CO lY r CHECK if BILLING ADDRESS <br /> {'►4 PHONE# Ex-r. <br /> BUSINESsNAME I/lWG j 916 33 — ttr � <br /> HOME or MAILING ADDRESS FAX# <br /> ,. rr P. 0 �© 1C IoZ � (%6 ) 3 a-3 - 1r <br /> W <br /> CITY EST A L 2�"I !M +A%�� STATE C A zip of <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of salve, <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,StandtA <br /> DERAL laws• <br /> 4 <br /> APPLICANT'S SIGNATURE: DATE- <br /> PROPERTY/ <br /> ATE= Z I a <br /> PROPERTY I BUSINESS OWNER❑ NAGER OTHER AUTHORIZED AGENT 14 C <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/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. <br /> TYPE OF SERVICE REQUESTED: -P tti V t I;n+v <br /> COMMENTS: PAYMENT H LEI 4f I I <br /> REOGIVED APR <br /> , S, 2 <br /> 08 <br /> APR 2 LUUt3 Fhl'f9R01fU1Lf1T i4FALTH <br /> SAN JOAQUIN 'T,-jFQ"�'�1' Cr"''/I`! <br /> ACCEPTED BY: t HEA �r l j Z DATE: t'e Z 3 1 y <br /> L L c- – ,ff <br /> ASSIGNED 70: 'l,'°� !\J L.C I EMPLOYEE#: ( � DATE: �f (� <br /> Date Service Completed (if already completed): SERvice CDOE: �' P i E: �C,Q <br /> Fee Amount: ci G�} Amount Paid Payment Date �� <br /> Payment Type Invoice# Check# Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> REVISED 1111712003 <br />