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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property LP, <br /> ITY ID# SERVICE REQUEST# <br /> a 00 31 IA �OWNERIOPEfjQTaO's VF ,p�'ll 'µ eD PC, C C)AW/�� CHECK If BILLING A0DRE55FACILITY NAMED / t/�� 1�F�L�L(/J / G,tAf,N/li� d/, /,/} ^VVyV� try G c- <br /> SITEADDRE$S 2-233 Gh'" '' Y✓ Gl/r�`�YI ✓�. •SI � CV` 1�� r`020 - <br /> Street Name CI 21 Cade <br /> ffireet Number Direction u/ O rl ( V& <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2/ d � O`- <br /> Street Number Street Name /y <br /> ClSTATE Zip CITY �� �� P (i 4 <br /> PHONE#1 QJ ° I �y/ IT APN# LAND USE APPLICATION# <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /r A ,/�� I �1 Id //[)/� CH�E/CK If BILLING ADDRESS <br /> ./ `L/�✓i/I/�/�- PHONNE# �' I p _ Ezr. <br /> BUSINESS NAME C V I A (,A J fl�E` 1 z' <br /> �l/� IV" ll U FAX# <br /> HOME or MAILING ADDRESS 1 v-r6 �/ / �,( A t ( ) <br /> CITY 1 CIV �rC ✓� (}r`�t l STATE ZIP a <br /> BIL <br /> L <br /> INGACKNOWLEDGEMENT: 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 business as identified on this form. <br /> 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 FED laws. / f� <br /> APPLICANT'S SIGNATURE: �• S ��� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANTS not the BILLING 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 asses information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It Is r ) Or <br /> my representative. ac <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: ^ ^^ ^ ` N�AQu/N C <br /> ?018 <br /> j`re l/Y\ r VN NfALTHO vAdev NAY <br /> RrA4F <br /> ACCEPTED BY: v <br /> EMPLOYEE#: DATE: �. j2 l6 <br /> ASSIGNED TO: <br /> EMPLOYEE#: DATE: LI I2I jJ <br /> �='�/ .TJ����f <br /> Date Service Completed (if already completed): SERVICE CODE: d(..QA PIE: 1140 2 <br /> Fee Amount: Amount Paid , 4?, Payment Date 1 <br /> Payment Type (y)p ,. Invoice# Check# Received By: <br /> SR FORM(Golden Rod) <br /> EHD 48-02-025 <br /> 07/17/08 <br />