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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property , FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR r <br /> a.gECK It BILLING ADDRESS <br /> FACILITY NAME L- V1\'S cv 1 �\ �J V Il•� �J I V J t 1 <br /> SITE ADDRESS ��� 1sc'a n <br /> t <br /> Street Numbler Dire n StreerName -C, ,Cht I Zip Code <br /> HOME or(VVIAII Iuc A^MmSSS. Cif Di for, #frnm Site Address) <br /> _ 111 ! � C � . <br /> Street Number S Street Nam <br /> CT7 �� ST TE ZIP / <br /> c �U <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 0b-PHcO 50b- <br /> PHONE <br /> ONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR „ ` 1A (��{/� CHECK It BILLING ADDRESS <br /> BUSINESS NAME `lJ v 11 1l U V111/i J \tJP1H10NJE Ex'' <br /> 4c+it ' s ��Y _q <br /> HOME Of MAILIN ESS ;\_ � !, FAX# <br /> 1111 GY 1 , t ) <br /> CITY 5cc� 0/1\ STATE IfA ZIP <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 or <br /> activity will be billed to me or my buaiiriess as identified on this form. <br /> 1 <br /> also certify that I have prepared this application and tha the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FE DE I `S. <br /> APPLICANT'S SIGNATURE: 1 DATE: V <br /> PROPERTY I BUSINESS OWNER QPERA I ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the J91LLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessmentp gia�tio_n <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is prOV M <br /> my representative. •�/`C7+'Vi` <br /> TYPE OF SERVICE REQUESTED: y <br /> COMMENTS: JO QIJ g 14y <br /> ol� <br /> COU <br /> I T <br /> , <br /> ACCEPTED BY: \ F EMPLOYEE#: DATE: <br /> \ �7 <br /> \ <br /> ASSIGNED TO: _'( EMPLOYEE#: DATE: ` \c <br /> Date Service Completed (if already a mp(ted): SERVICE CODE: ; PIE: , <br /> Fee Amount: Amount P /Sa d D Payment Date <br /> Payment Type Involce# Check# CP Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> 9 S <br />