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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT d'- <br /> SERVICE REQUEST <br /> 4 � <br /> Type of Business or Property FACILITY ID# SERVICE REQUE T# <br /> G-tAetj- t& F%cno I qq 31Z6b-7-7`54' <br /> OWNER I OPERATOR n <br /> CHECK If BILLING ADDRESS LJ <br /> FACILITY NAME F M_v-kG+ 1 <br /> 1c <br /> SITE ADDRESS 25770 Ere <br /> Street <br /> t�navtifi <br /> Street Number Direction Strout Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) g510 DAQFle <br /> Street Number Street Name <br /> CITY STATE' ZIP <br /> E I k G-rovc CR <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (91 fv 1 2°13- 1 If 74 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> 1 ) ©0 © I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR y <br /> Ar of tM 11 S• SA v%d�k CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ems'_' <br /> F P Msvke+ 111,& 293 - 11471 <br /> HOME or MAILING ADDRESS FAX# <br /> 1590 iia le 6"a V lace ( ) <br /> CITY E IK f..rOV[ 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 liroject <br /> or activity will be billed to me or my business as identified on this form. _+ <br /> lr i <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 JOQUIN <br /> COUNTY Ordinance Codes,Standar TATE and FEDERAL laws. �,- <br /> APPLICANT'S SIGNATURE: DATE: 0.7 0& I ' <br /> T.- I <br /> PROPERTY'/BUSINESS OWNER O RATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is 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 locatdd;at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available&p4 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED; Ft7)odJut <br /> COMMENTS: aSAV <br /> J <br /> O <br /> ` C n a vig e� ©q ©�►:Yl ed` H4WiRQNM OUN», <br /> H QEp���NT k a <br /> I - <br /> ACCEPTEDBY: EMPLOYEE#: DATE: 7- -7' <br /> ASSIGNED"70: EMPLOYEE#: DATE: "7. -I" <br /> wn <br /> .F:.: <br /> Date Service Complete (if already completed): SERVICE CODE: `D `" P!E: <br /> Fee Amount: Amount Paid#/ �� Payment Date 7 <br /> PaymentJType O t1,1 Invoice# Ch k# ��rsl3 Received By: <br /> <. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />