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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNIENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F S (-Dora fZ> 5-r�v N - 8 © 126 2-& <br /> OWNER/OPE/RrATOR <br /> {—ru , CHECK if BILLING ADDRESS O <br /> FACILITY NAME <br /> SITE ADDRESS <br /> 1 Lo1�3u (n c5:& <br /> Street Number Direction Street Name C <br /> ity <br /> HOME or MAILING ADDRESS (if Differ t from Site Address) Zi Coae <br /> CITY <br /> Street Number Stree a e <br /> =t` s� Mj v t (t ��� STATE ZIP <br /> PHONE#1t 1 <br /> 19 PEXT. APN# LAND USE APPLICATION 6 # <br /> Fi0N1\E#�IY�2S / ExT- BO$DISTRICT <br /> ( ) lOq S�O LOCATION CODE <br /> -- <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR _ �1'^"' <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME f- t� v �}n 1 <br /> `"1"1 i �-�-� t ExT. <br /> HOME Or MAITV�r7 �� v�t� p FAX# <br /> CITY //�J t�^� <br /> WC�T LAw—tc I [.�E STATE n A ZIP X1.1 27 <br /> BILLING ACKNOWLEDGEMENT: 1, 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,STA nd A <br /> APPLICANT'S SIGNATUR :� <br /> DATE: <br /> PROPERTY/BUSINESS OWNER/ OPERATOR/r IANAGER ❑ ER AUTHORIZE GENT❑ <br /> IfAPPLICA,�is not the at 1, P IRTY.proof o rrthorization 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 environinental./site assessment <br /> infonnation 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: A� <br /> COMMENTS: c <br /> OR ? Eo <br /> SANTO 4 ?019 <br /> FN gQUI <br /> H�TN EP FNTq��'1' <br /> ACCEPTED BY: EMPLOYEE#: <br /> -7-13 DATE: / <br /> ASSIGNED TO: EMPLOYEE#: <br /> DATE: <br /> Date Service Complet (if ready completed): SERVICE CODE: r <br /> Fee Amount: ( Z PIE: <br /> Amount Paid <br /> SZ, Payment Date -2-0 �q <br /> Payment Type Invoice# / /I Check# Received By: /(& <br /> EHD 48-02-025 6 ►l-1 '1 9 Z) tY`T Z7 3 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br /> 12o V*A--o S <br /> 5 telf"l0 <br />