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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OW E /OPFERATOR <br /> O /� ✓q.reZ CHECK If BILLING ADD E <br /> FACILITY NAME N <br /> SITE ADDRESS <br /> 1653Esc�tar/-13ELt ci.4 Jen L '.�T��.� 987,36 <br /> Street Number DI ctlon S Nema Cft ZID Coda <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Stroat Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ezr. APN# LAND USE APPLICATION# <br /> ( ) 0 P A- - 1 0016 -3 <br /> PHONE#2 E><r. BOS DISTRICT LOCATI N CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REpUESTOR ^7 m <br /> Kro r` /-14�d-e/ / iW/L IVCHECK if BILLING ADDRESSO <br /> BUSINESS NAME r/�1.� IO� !)_[ Jr L� PHONE# T <br /> t `( 709 *3`/-806/ 3 <br /> HOME Or MAILING ADDRESS FA%# <br /> p, o, ljoK 7,160 1209 )33y—o7z 3 <br /> Crrr (rD l]t� STf*E ZIP <br /> J g� <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 certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, <br /> ,�STATE <br /> Eaannd FEED(WL laws. <br /> /` '/ <br /> APPLICANT'S SIGNATURE: /stir c( j)y`6we4 DATE: Z��Y� /7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT D.l, �JJrJC7/�✓' <br /> IfAPPLicANT 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 <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 JOAQUrN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at�yype time it is <br /> provided to me or my representative. I / _ n <br /> TYPE OF SERVICE REQUESTED: ED <br /> COMMENTS: SAN,/ 2014 <br /> AQUpy <br /> OF-471,1'"04iOq 7AI- <br /> �•AIr.Jd) <br /> ACCEPTED BY: EMPLOYEE#: DATE: 2. L( t 1 (4 <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S'�2 P JE: 2L 0 <br /> Fee Amount: Z5—c) ` Amount Paid .25-0-0D Payment Date <br /> Payment Type Invoice# Check# �$ 3 s Rec ved By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />