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N <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RE57AU e arJ-r- I N E V_ .SROs 7 " <br /> OWNER/0P ATOR <br /> A L7UGYz�GYl0 4 /t _ -I.r(QQ� ��r_ CHECK if BIL'.ING ADDRESS <br /> I LT <br /> FALWTV NAME el-i•LE�w='L�• <br /> 6!u eya4 A &Akl AomeoLD <br /> SITE ADDRESS l - <br /> E, r�totvuA }.�' EI rltaeAAA lftNC -6-0 I <br /> ymr d ia,79 Stree' amber I -I- City _ Zfp Cade <br /> HOME Or MAILING It. P11 , If Di,ferent from Site Address) <br /> _ _�91Fect Number _ Ser.Name <br /> CITY _ STATE <br /> �-'' <br /> i <br /> PHONE <br /> p#Z BOS DISTRICT LOCATION COOF <br /> (ems✓-! �/ --.7F� - �� ✓ _._- _ _—..-_. J <br /> C�CNTRACTOR / SER.VICE REQUESTOR ++.. <br /> REQUESTOR n,�v�12� CHECKIf BILLING ADDRESSE. <br /> I A ewjr- <br /> � IJI <br /> BUSINESS NAME -- �� PHO <br /> NE# Exr' i <br /> - -��C14AwM.rs �gc—reucrroa� SNG. RI�s)_SL�I '66`79 x,207 �I <br /> H,rnF.or MAILING ADDRESS FAL <br /> CITY l^CEM� STATE fA zip 4I <br /> 5,-ra r <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 will this project cr <br /> activity v.'11 be billed tome or my business as identified on this fora. <br /> I al:o Certiry that I have prepared this applicatior end that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> Co r'rr Ordinanre Codes, Standards, STATE and l En-RAL laws. (� <br /> APPLICANT'S SIGNATU?E: DtTE: 2S'�C71S <br /> PROPER`Y/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT _ <br /> If APPLIC4NT Is not:.he BILLING PARTY,proof of authorization to Sign is required Title C02P--6 rt-' <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located st the above ;� <br /> Sita address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at 'he same time it is provided to me or <br /> my representative. <br /> TYFE Ur SERVICE REQUESTED: / <br /> COM'°NT- <br /> —� u n� <br /> ACCEPTED BY: f}�q / /C EMPLOYEES:-- ---- DATE: / <br /> e ASSIGNED TO: ^( / L —_— EmPLOYEE#: DATE: v - <br /> Date Service Completed (if alrea,,y."mpleted): _-I_:ERwcE CuoE: fp/ <br /> E: <br /> Fee Amount. 00 Amount Paid , z<= Payment Date <br /> Payment Type Invoice# Check If <, Received By: <br /> EHD 48-02-025 AUG, L U 2015 SR FORM(GNJen Rod) <br /> 0'/17/08 <br /> SAN JOIITOw7ENT, NTM <br /> AL <br /> HEALT H DEPAIIiMENT <br />