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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR _ <br /> Z- v t fj 1, p 7 n� D �i i/1� y �� Co J LJ'C ' <br /> r CHECK If BILLING ADDRESS <br /> FACILITY NAMESrrE a`�' 1 J 1. lJ C1'r I \J 1..� <br /> tv ) 7 J n <br /> ADDRESS <br /> />7 Streel Number Direction Street Name CI Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address � 10a <br /> 37 Street Number Y Street Name <br /> CITY�ri�-rb SM ZIP <br /> PHONE#t En. APN# LAND USE APPLICATION# J bb <br /> 0:9 3gC-) <1 le co z2.0 <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> j }^� .j� Hyl ' 1 �/�i. / CHECK If BILLING ADDRESS14 <br /> BUSINESS NAME / U �V V I /v Ems' <br /> —� 1 SLA�rJ i3 YL wt i� PH�O05) 3S>0 Z <br /> HomeVr MAILING ADDRESS FAX# <br /> 3 I Ci)Av�—e�2 <br /> CITY ,nn o o-e-gro STATE • yl , ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedagentof 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�as at th ork to be d will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STAT t71'EDERAL I -7 ) <br /> APPLICANT'S SIGNATURE: DATE: J / <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ 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 located at the above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is provided t0 me Or <br /> my representative. <br /> TYPE OF SERVICE <br /> REQUESTED: { IIr t I5LAU >ah M/Vl+:;4t(cU JC 3�1(�G4f .... <br /> COMMENTS: <br /> VS?0qV 3 0 n NR / A�ft <br /> e?v <br /> '4 0 <br /> 12 0 ,"`-+IPRev;e -IQ/e(I)P) <br /> 9 <br /> ///���777 .D H�Nt�RO Uby CO j <br /> ACCEPTED BY: /' r s S j EMPLOYEE#: DATE: 3_I pAR C <br /> ASSIGNED TO: S k i h EMPLOYEE M DATE: 3- ) q-I Y <br /> Date Service Completed (if already completed): SERVICE CODE: 5 :23 PIE. z(Gy <br /> Fee Amount: Amount P Payment DateIG <br /> Payment Type Invoice# Cl3S� Recleiv dBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/77!08 <br />