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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> JZ es�avvan`r rADoo -6-L95 <br /> OWNER/OPER ATOR }t t� <br /> Tp SeFt� O� 0.nA 4V 0 r'„i� CHECK If BILLING ADDRESS® <br /> FACILITY NAME Ta r lo. L a COm adreS <br /> Sf1E ADDRESS <br /> Street NumOer q tion ✓�G Street Nam -{}- `�` J J f�V <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> -::KP L< P <br /> I q :: t Street NumGar �r IGrVon tree�ame�' " <br /> CITY zip <br /> Sf-c,, <br /> _ ,n STATE_ 95 n ^` ^ <br /> PHONE#1 �O E"' APN# `ANDUUSE APPLICATION# /1J V/ <br /> Qtq $3D -14U <br /> PHONE R Ear. ENDS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR A A r� Eve* b er-er re, <br /> t`r, CHECK If BILLING ADDRESS <br /> BUSINESS NAME Ta PNDNE# —' Em. <br /> HOME Or MAILING ADDRESS551 h /t (A%# i <br /> CITY 'rA V Yyl� I�il STATE 7JP 95 LIU <br /> BILLING ACICN WLEDGEMENT: 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 forth. <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:mwi" 6tiolfAleL� DATE: -" <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAGER O OTHER AUTHORIZED AGENT <br /> IjAPPucavT is not the BILLING P,IRrr.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 REWESTED: <br /> COMMENTS: <br /> Gnarti�e o� owner - InspeGi-la,-. <br /> ACCEPTED BY: . mw Y1 O EYEE#: DATE: <br /> ASSIGNED TO: ICU UYI PL YEE#: DATE: __ <br /> Date Service Completed (R already completed): SERVIICE CODE: PIE: ` �2 <br /> Fee Amount ' CJ 2• QO Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br />