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LVCa-h'or ` OPC()�AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> V-Z8 // K SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> elad f Vl �10 -7 90 �� <br /> OWNER/ O TOR <br /> �5 CHECK if BILLING ADDRESS <br /> br <br /> FACILITY NAME I <br /> SITE ADDRESS�iJ 05 <br /> ChenKee Ln St i f e 10 Lid r g5ayo <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING.ADDRESS (If DSfferent from Site Address) 3(� gocl('p 6/ i Or 4- 531 1 <br /> Street Number (/f L Y f Street Name �V <br /> CITY J��� �. STATE CA <br /> ZIP qI %E <br /> PHONE#1 ExT• TAPN# LAND USE APPLICATION# "f ((/ <br /> (qaS) 905 yoo g52(o �A-1�-)1u 1-1 <br /> P ONE#2 EXT. BOS DISTRI T LOCATION CODE <br /> (��5) 5 Lf BSI oo ©-J- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS■ <br /> Dv -Pay- 60(s b -ts <br /> BUST SS NAM PHONE <br /> DISCDttlifs s) &S qot) Exye'(p <br /> HOME or MAILING ADDRESS FAX# <br /> Pf (BHI) g 3°i- 8 3 3 n <br /> CITY Lt b vi' STATE /! ZIP QY5('eQ) <br /> :�] <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 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: dA eJDATE: <br /> PROPERTY/BUSINESS OWNER❑ Y OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Business License Sgeclalist <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title4' r'!oV7- <br /> above <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/si sseslw� <br /> information to the SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the S sti'b5 it.i�� <br /> provided to me or my representative. P —;;VSO ` J 1 8 <br /> TYPE OF SERVICE REQUESTED:�-H�f�M f hI� Ins ec-Fi'vV] - W Pe �o� 5 ��ofnfi.� s ► �T R0NME our. <br /> COMMENTS: L655 tVI/ / <br /> V l v"V S �'e-e� O1- ,)1 e -PA tK a je'6i F-VOC4,, TItiJF �, <br /> ' .MC Se Sfrld DVI' i,n AJ V COI st t rn a�-�-en-fir ► Gam' -�h� <br /> cf('0y1 �.rc es lc+C e ' we- wl �� �sc*id Orr irlal fo fOe- store . <br /> -F�nG�I �� � P 9 <br /> ACCEPTED BY: EMPLOYEE#: DATE: 1 ,�✓,I <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5;) 2 P�11 E: '�0 <br /> Fee Amount: 0o Amount Paid ��� du Payment Date <br /> Payment Type Invoice# Check# f/33 Received By: <br /> EHD 48-02-025 O SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />