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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Ty of s' ess or PrqpQI;ty FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPER TORD� `1J11 ` n, <br /> p CHECK if BILLING ADDRESS <br /> FACILITY No,M���, <br /> SITE �J11 �l 1`V`/�1l\ 1N" ' <br /> c I C+� Tc(�-&.C(P- <br /> Vg� <br /> �r Direction ' _" StreefName Cit `�1'r <br /> HOME or MAILING ADDRESS (If Different from Site Address) ij, t� r `1�,1n,�(� �'/^(�n M'S sty + S_�1 <br /> Sficol Num6ar lJl`^t 1 1 Y c � <br /> Street ate T <br /> CITY � /��_� ^ STATE ( ,t A- ZIP <br /> P #1 �'4 `5��5 APN2-(-4, IS- , LAND USE APPLICATION# <br /> PHONE#Z ExT• SOS DISTRICTLOCATION CODE <br /> ( ) <br /> / SERVICE REQUESTOR <br /> REQUESTOR�"(� 1V� <br /> 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PyQ1�E# AE ,425-0 <br /> HOME Or MAILING ADDRESS �11'`V\.+r ICyvW 1vW�1,V � FAX# <br /> ( ) <br /> CITY 1bgb � �STATE 4 ZIP qo( ci- ' <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 t the work to be performed will be done in accord nce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATEEQQand FI <br /> ER)'L laws. <br /> / 1 <br /> APPLICANT'S SIGNATURE: ` ` y DATE: ` I� <br /> PROPERTY/BUSINESS OWNER❑ OPERA )R/MANAGER ❑ OTHER AUTHORIZED AGENTEr- <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION 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 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: T)QedAd INCIP Chk ct, <br /> COMMENTS: (21-1 l <br /> ACCEPTED BY: W 7 EMPLOYEE#: DATE: <br /> ASSIGNED TO: {� C4 EMPLOYEE#: DATE: ./ 11-4 <br /> Date Service Completed (if already ompieted): SERVICE CODE: PIE: 1601 <br /> Fee Amount: (DU Amount Paid .0( Payment Date ( (O ($ <br /> Payment Type lS Invoice# Check# Received By: , <br /> EHD 48-02-025 �+ O T '9 fr SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> A <br />