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SAN JOAQUIN COUNTY ENVItONMENTAL,HEALTH DEPARTMENT , <br /> SERVICE REQUEST <br /> Type of Businesp,or Property FACILITY ID# SERVICE REQUEST# <br /> 1 ,5)C voy z77 (,7 <br /> OWNER/OPERATOR It <br /> CHECK It BIL TNG ADDRESSE <br /> FACILrrY NAME <br /> 1 <br /> $READDRESS •� . Ct� <br /> me r <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> street Number Street Name <br /> [PHONE#2 <br /> pp <br /> JTATE ZIP <br /> E#1 Exr <br /> I1APN# LAND USE PLICATION# <br /> - D - 623 <br /> ) BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REgUESTOR (//�(y�Qp <br /> Wl�G K ���� CHECK If BILLING ADDRESS El <br /> BUSINESS NAME <br /> �i aT.L �l� .� ✓ •9 7/l�Exr. <br /> HOME or MAILIN ADDRE S The 7y.Zan le Co <br /> ��io <br /> Cm g` mmU Ch <br /> • �'ww.trianglecorntnurt f'Ch <br /> ychurc corn <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or bus <br /> acknowledge that all site and/Or ro'ect ' <br /> P 1 specific ENVIRONMENTAL HEALTH DF Keith Tankersley <br /> activity will be billed to me or my business as identified on this form <br /> Senior pastor <br /> I also certify that I have prepared this application and that the work to be per 16100 E•Harney La <br /> COUNTY Ordinance Codes,Standards, STATE F$pFRAr 1 Lodi' CA 95240 <br /> Sunday Service 70 AM Church(209) 727-5751 <br /> Cell )481_ <br /> APPLICANT'S SIGNATURE: Home(209 0347 <br /> DATE: ) 7_7 0445 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AGER ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authoriZation to sign I is requiredTitle <br /> ❑ <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 <br /> HEALTH DEPA <br /> provided to me or my representative. RTMENT as soon as it is available and at the same time it is <br /> TYPE OF SERVICE REQU----- <br /> COMMENTS: <br /> FAYiV1l=I--J <br /> moo/ S <br /> RECEIVED l�vfA� <br /> S N JOAOU1��6/h'I�n <br /> ACCEPTED BY: % VIRONMENTAL <br /> EMPLOYEE#: A I <br /> ASSIGNED TO: <br /> ATE: O S <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): <br /> Fee Amount: � SERVICE CODE: � PIE: O <br /> Amount Paid q / <br /> Payment T e b 5- # C� Payment Date rC) <br /> Invoice# Check# -' -'�,� <br /> Received By: <br /> EHD 48-02-025 - <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />