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SAN JOAQUt,. COUNTN' ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ��T,�v1 � Dk-0o -7tC/ !C) <br /> OWNER/OPERATORfl\ " <br /> ��� �� 1�1( CHECK If BILLING ADDRESS <br /> FACILITY NAME c'p 1/5�i�JYOk — <br /> SITE ADDRESS 2-966> � ./ � � U-1,11---- I-xD <br /> Street Number Direction Street Name Cit ZIv Code <br /> HOME Or MAILING ADDRESS (If Different�ro Site Address) <br /> O Street Number F� 1-i-► Street Name V <br /> CITY I�I 1 / STATE ZIP <br /> PHONE#1 ExT. vim- APN# �LAND USE APPLICATION# <br /> hes ) X35- �35� -7,3� - L o D - I <br /> PHONE#2 Ex-r. BOS DISTRICT LOCATION CODE <br /> ( ) dG S 11 t <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR FICB4��IZF CHECK If BILLING ADDRESS <br /> BUSINESS NAMEVA <br /> JvOU3J 'Z� l tC,S ) 1 + ^ Exr. <br /> HOME Or MAILING ADDRESS 4 <br /> /00 ^ ' FAX#2-04- <br /> CITY STATE(7-A ZIP C� (�O <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certity that l have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stnnds ST E a E ER <br /> APPLICANT'S SIGNATURE: CSS ' JS <br /> DATE:: <br /> PROPERTY/BL5INBSS OWNER❑ OPERATOR/N'IANAGER ❑ OTHER AUTHORIZED AGENTA AF-CATRz-c-T <br /> ff,4PP1.ICIN7'is not the BILLING PARTY,proof of authorization 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 environmental/site assessment <br /> information 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. /J- - <br /> TYPE OF SERVICE REQUESTED: l'�' Pc� P <br /> COMMENTS: Reclely pn <br /> JAN 26 ?i71. <br /> HEq 31AQ01w CpUNry <br /> TH DEp MTAI <br /> ACCEPTED BY: �A ny,� EMPLOYEE#: DATE: ' <br /> ASSIGNED TO: All EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Ar2-3 7 <br /> 1 E: 16 6 <br /> Fee Amount: Amount Paid b Payment Date <br /> Payment Type S� Invoice# Check# Ll l 6P2-q0 Received By: (g <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />