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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of BL si ess or Prope y FACILITY ID# SERVICE REQUEST# <br /> c�'v , <br /> OWNER 1 OP BATOR <br /> CTA li kS CHECK if BILUNG ADDRESS <br /> FACILITY NAME �;T*,`gUC kS. <br /> SITE ADDRESS -•f p�� It/n/_ L Q� j� �� 91 jSO GA <br /> L Sltreet Number Direction V r 1�l `�L•Street Name V CRY Zio Code <br /> HOME or MAILING ADDRESS if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> c 1 2tL2- 1o7,'C <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> 1 ) GJ S �� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR >AY R c ` <br /> LO o N IQ a CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> Wk (So -IC31 -162to 3 <br /> HOME or MAILING ADDRESS FAX# <br /> (� S 12'LAIL ( l <br /> CITY TbQ()A.,tc/ STATE CIA ZIP �` 1 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 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: pt ,� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OK-'BATOR/MANAGER ❑ OTHER AUTHORIZED AGENT" <br /> IfAPPLIC.4NTis not the BILLING PARTY proof ofau thorization 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 thsame time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: tY r?. PL ISI.( eiviev , <br /> COMMENTS: I <br /> i ov- SFP?8 ?418 <br /> V yE9CT <br /> CO <br /> "14 yOFagR"14 <br /> ACCEPTED BY: qct`- 4 w EMPLOYEE M DATE: <br /> Li� <br /> ASSIGNED TO: ✓� Y '0,� S EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �� P 1 E: <br /> Fee Amount: Amount Paid15/4 D� Payment Date 9 !g <br /> Payment Type Invoice# rv0 Ch k# �'3�q��� ece ed By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />