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Nov, 11. 1014 10:53AM San Joaquin Uounty No, 1519 V, 1/1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> outer �� �z� WO -2)V-cull o:t;q <br /> OWNER I OPERATOR <br /> CN6cK If BlLutlo AV,M,ri <br /> FACtL1TY11tAME <br /> SITE ADDRESS <br /> 91reel Number Dlredlon Str6allIsmitCI i C <br /> HOME or MAILING ADDRESS (If Different from Silo Address) 1 <br /> �SOW N�mb6r ��t1�L.. """ m, <br /> CITY $TAE zip <br /> �Nax V�u- `7 <br /> PHONE 81 APN I/ Wo Use APPLICATION n <br /> �65� 9ZZ-1�L3 L(lo7o CO <br /> PRONE02 Bim• BOS DISTRICT LOCATION CODLr <br /> ( vv l ©1 <br /> 'CONTRACTOR/SERVICE REQ'UESTOR <br /> REQUESTOR 1:;Pt+" �� 1 <br /> ( CHECK It BILLING AO�1 <br /> RuslNess NAn1E5 b �C �,�,> y�G 4- SDC73 <br /> HOME 1 INO ADQ$ES9(, me+- HL y� ) ( ) <br /> CITY I &w"j:SCJ t�q/,] ` STATE zIP 7 <br /> 13ILLING 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 application and!fiat the work to be performed will he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAre and r2DET la <br /> V�)APPLICANT'S SIGNATURE: DATE: (t <br /> PROPERTY/BUSIN433 OWNERCI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Dir ��' <z-,,�Ccs <br /> IfAvpt.loAmr is not ft BILLING PARTY proof of avffiorizatton to sign Is required Thle <br /> AUTHOR17ATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above <br /> alto address,hereby authorize the release of any and all results,geotechnical data and/or environmental/slle assessment Information <br /> to the SAN JOAQUIN COUNTY 5r'IVIRONMENTAL HEALTH DEPARTMENT as soon as It Is avallable and at tho Same time It Is provided t0 me Or <br /> my representative. <br /> TYPE OFSERVICEREQUESTED: _7 RECEIVED <br /> CoMMrlrrs; <br /> N0,21 2014 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HMTH DEPARTMENT <br /> ACCEPTED BY: V I '�l1^7 EMPLOYEE#: DATE: f i Z1 00 <br /> ASSIGNED T0: EMPLOYEE#: DATE: <br /> Date SelvIlce Completed (If olrana completed). SERVIC9CODE: - �F�2 PIE: &D / <br /> Fee Amount: Amount Paid GID Payment Date I ILA I <br /> Paymont Type V/ Invoice# Check# Received y: <br /> EHD 48.02025 SR FORM(Golden Rod) <br /> 07/17/08 <br />