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,64-x2q 4(oq--6 ` 38' 4 � <br /> pSAN JOAQU)r OUNTY ENVIRONMENTAL HEALTH PARTMENT I L <br /> N�� 3L4 Z -d SERVICE REQUEST P" T' <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1� ear WAgti <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> FraNGelleE7Sceioav- <br /> FACILITY NAME r�r Q tf,,.1�.,1J ✓� G <br /> A Li k� e cN <br /> SITE ADDRESSo Se <br /> S7Wmr 01mato T1ty <br /> �.0-a q,�j 33C6. <br /> HOME Or IL IN ADDRESS (If PDifferent from Site Address) WxY bdr G{— <br /> `�17 rO ` Street Number Street Name <br /> CIT, 1�/�,y STATE ZIP q S rt <br /> CA- <br /> PHONE#1 EXT. APNIt LAND USE APPLICATION# <br /> l" (ZC51) ZSI t+- 3 TZ W <br /> PHONE 92 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 -7-Sq l 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �� n' I H CC if BILLING ADORE <br /> -Fya L2 Sa <br /> cb0. ekl6 <br /> 1 PHONE# ExT. <br /> BUSINESS NAME(.1�e L.0.$ OwI�P_I/' LR <br /> HOME or MAILING ADDRESS IV FAX# <br /> Ao.SaK (bs� <br /> 12CR <br /> CITY STATE ZIP q 5Z� <br /> BILLING ACKNOWLEDGE : I, the undersigned property or business owner, operator r ggpyi p pry e, <br /> acknowledge that all site and/Or project Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charge I ct <br /> MENT <br /> or activity will be billed to me or my business as identified on this form. OCT <br /> C Qq (� n/l <br /> also certify that I have prepared this application and that the work to be performed will be done in danceTh�l QIAOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FEDERAL law �RWVh�EkW(y/,�M/I��ALTH <br /> APPLICANT'S SIGNATURE fie' DATE: / ��BRYST �+`r`S <br /> Q /L <br /> PROPERTY/BUSINESS OWNE OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPLICAI7 is not the BILLING PARTY proof of authorization to sign is required Title <br /> AU'T'HORIZATION TO RELEASE INFORMATION: When applicable, 1,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 COON rY 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: User /hT-e <br /> F"t7- �/ <br /> �STCOMMENTS: 7 O t`� plae'InZg 'e\'//S+/-/V01 <br /> ml- qq �L D z�0, OCT 2 9 2010 <br /> SPAN UOgONMENTAI- <br /> OUNTY <br /> ACCEPTED BY: V EMPLOYEE#: n 3,7-f <br /> ASSIGNED TO: EMPLOYEE#: v&it <br /> DATE:I ry[3 <br /> Date Service Completed (If already completed): SERVICE CODE: D' t P l • Z306 <br /> Fee Amount: Amount Paid Payment Date a D <br /> Payment Type Invoice# Check# 02 Received By: <br /> OCI— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />