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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> EMIL �QSW Ai �--NC O-, c't C RS1D W15� 8 I1 �&79VI- <br /> OWNER/OPERATOR <br /> S A� CHECK If BILLING ADDRESS <br /> FACILIT�Y"'CNAIlE <br /> w Pry( v viEL Lc til i L3k- 1-10 <br /> SITE ADDRESS Nc`�N(• w c GJ�00 y_` cl G 2-0-7 <br /> Street Number Direction lStreet Name Cit � I JZi Code <br /> HOME Or MAILING ADDRESS <br /> (if <br /> Different from`Site Address) <br /> 7 Al~C..ti�1/�� hL.l. �C.�. Street Number Street Name <br /> CITY^La� � 9 &K C1 <br /> ZIP C1 4' a 9 <br /> PHONE 1l#/1 EXT. APN# LAND USE APPLICATION# <br /> nZ51 Lib '�o00 <br /> PHONE W2EXT. BOS DISTRICT LOCATION CODE <br /> Ali) LM - w3 L0.Sf- �tL�on1 C�r1�ILPcI, Z <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �` CHECK If BILLING ADDRESS <br /> i BUSINESS NAME 1 PH E# EXT. <br /> �r <br /> 1. ( C C. °� AA . ,0 <br /> HOME or MAILING ADDRESS FAX# <br /> 16 b 0 V31 U-1 Ng\,S -G-r . c All bbf.-21�D <br /> CITY ` STATE 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 business as identified on this form. <br /> I also certify that I have prepared this appl atio and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STAT n FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ' DATE: \a ( 04 (- <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT (ZOS�(� toys 6y- <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required 7 irle <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 ai%essment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same tin2e I vided to me or <br /> my representative. .. "' '®ZtA <br /> s <br /> TYPE OF SERVICE REQUESTED: V n rg 1t r �✓ i��s' <br /> COMMENTS: 'S41V <br /> � <br /> ?018 <br /> OcpgRT T�N� <br /> MF�'T <br /> ACCEPTED BY: J^ � EMPLOYEE#: DATE: `t; / <br /> �I'l (� <br /> ASSIGNED TO: �/1 I^ ,� v`!�n Q EMPLOYEE#: l(� Z( DATE: (t v +`� <br /> Date Service Completed (if already completed): SERVICE CODE: I q g PIE: J30g <br /> Fee Amount: T Amount Paid Y(O,L/o Payment Date LO <br /> Payment Type _ Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />