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SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> .,1 -7 S(ZcC) q�g4y <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS D <br /> FACILRYNAME <br /> SI EMDRE;S <br /> ,. .' Street Number r n tr t Ne i Ca <br /> HONE Or MAILING ADDRESS (If Different from Site Address) <br /> Strutt Number Street Nerve <br /> CITY STATE, zip <br /> PHONE 91 EXr. APN# LAND USE APPLICATION 1f <br /> PHONE#2 EXT. ENDS DISTfttCT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUEST-OR <br /> REOUESTOR <br /> .`, 141- CHECK ifBILLINGADDRESSIS <br /> BUSINESS NAME r' PttNE# E"T <br /> HOME.ot'r LWG DRESS FAX# <br /> L <br /> CITY 7 i STATE 45,4 zip 1 <br /> BILLING.ACKNOWLEDGEMENT: 1, the utldersignod property or business owner, operator or authorized age.-not of some, <br /> acknowledge that all site and/or project specific ENVIRONMrN'fAL HPACTii D6.PARTMr!NT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this thou. <br /> I also certify that I have prepared this application and that the work to be perf'orme'd wilt be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standanis,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 2;,, _.___.---- DATe�t:tI✓°� ;,. ____ —/yJ <br /> PROPERTY/BUSINr.S.4OWNE.RL— OPERATOR/MANAGER ❑ OTHER AtiTBORiTi:.DAGENT Lu/q�+'/� �jrJ �IhINGiY <br /> If APPJJCANT IS not the/3[!L NG Pe RTP,proof of authorization Au.vigil is tegrdred Ti rle <br /> AAI THOR17ATION 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, gootectraical data and/or enviroamentaUsite assessment <br /> information to the SAN JOAQUIN COUNTY FNVIRONMENTAi.HEALTI'1 DEPARTMENT as soon as itis available and at the same time itis <br /> provided to me or my representative. S PAY(\A <br /> TYPE OF SERNCE REQUESTED: `J �Q/ 1 RECEIVED <br /> COMMENTS: <br /> NOV 0 8 Zoos <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: 9. t m Vv 4EmpLoYEE <br /> PLOYEE#: 3I DATE: // 66 <br /> ASSIGNED TO: � V #: 931 --7` --7 DATE: it 9 6g <br /> Date Service Completed (If already completed): SERNCE CODE: PIE: <br /> Fee Amount: ---TA U V mount Paid S (lD Payment Date \'- <br /> Payment Type � S Invoice# Check('1# Received By: <br /> EHD 48-02-025 2 B SR FORM(Golden Rod) <br /> REVISE01.1/1'11/17/2003 O J <br /> zoo 12 1VJ,NRlfN0NIAK21 J,1V,L TTOTSSS916 XVd ZD:£T 90OZ/SO/TT <br />