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s SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# ' <br /> OWNIER I OPERATOR CHECK if BILLING A13nRESS❑ <br /> STf s <br /> FACILITY NAME STv�q-e'`t�� <br /> SITEADDRESS <br /> ,$S1 <br /> Stat Number Diractlen Street Name t Zi Cad <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> OS bj N\)E, Street Number Str atN-ne <br /> CITY STATE ZIP <br /> PHONE#1 EKT. APN# LAND USE APPLICATION# <br /> (ZDCd -:�:>vs-t51 S Z Z <br /> PHONE#2 ExT. 1305 Dlrlc LOCATION E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ CHECK if BILLING ADDRESS <br /> oc rW" �d <br /> BUSINESS NAME PHONE# ' <br /> kA59M �1'l. f�IcJtint 1�S5�cif ES i�.fc. o So 5 <br /> HOME or MAILING ADDRESS FAx# <br /> 1111 SArTori Pt vE.• ( 1 p <br /> CITY —IFOf.r Pl,,JF, STATE CAA ZIP <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 applicat' 1 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard4, T• nd TC RAI I ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT P! AGo l T•q bwas$ <br /> If APPLICANT is not the BILLING PARTY,proofof authorization to sign is required Titte - > lt1 TV--r <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: �boa FIgCA w --�'1 A t-1 ,-AI itJJ <br /> COMMENTS: {Y1<C7 C>' $JCl tai S-rFwIS u cls (�o"5-1—: —'-00 <br /> Dtc,lN 1rq V`QV`3' f 'Fi KTt, CEC t Ar-s <br /> p 4--eJ <br /> ACCEPTED BY: F EMPLOYEE#: DATE: • , J <br /> ASSIGNED TO: ` �1� nf1 A J� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE:52_-:,k' PIE; <br /> fee Amount: ,)c, Amount Paid �� Payment Date Sz� <br /> Payment Type Invoice# Ch # y Received By: <br /> EHO 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />