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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ppSEER�RVICEREQUEST# <br /> .� _ �, C = � . ? >T�RP'— APr, <br /> K ocj � fir,—c+4 ,W(,36q I(,/ <br /> OWNER/OPERATOR .�^ {� <br /> T <br /> r��N I'-IL' t7 + .CIK- or-, CHECK If BILLING ADDRESS <br /> FACILITY NAME Kbn11-i1TH A. ANDS4iAR -I^r'. 1, <br /> SITE ADDRESS 27 Z;7c Nim'1H Mhr t<'rILLc. {��AD C aSsM'Eh'S= F <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �,) ox 3 z- <br /> Street Number Street Name <br /> CITY ` STATE LZIP ,52 - <br /> PHONE#1 (pA`- L(p g( EUC APN# ICA7l0 z <br /> moo_ ,O-- 7" /`�/ Q —� <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR t/�r r� <br /> yy>'1+.�'R �, C1.�rc'S`tS CHECK if BILLING ADDRESS� <br /> BUSINESS NAME PHONE# EXT. <br /> GURTIS 'chLG�NEBRtNG <br /> HOME Or MAILING ADDRESS FAX# <br /> 4-IB MR7714;EYy P: DAr-AI ( ) I., <br /> CITY '_•j IL STATE ZIP Cr-� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator orCauthorized agent of same,) <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated With tTIs proJeTF <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 02 oZ�lc� <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER OTHER AUTHORIZED AGENT ICJ1 'l+ur_),-.j�.£r<- <br /> IfAPPLICANTis not the BILLING PARTY proof ojauthorization to sign is required '71Ehl �- 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 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. <br /> TYPE OF SERVICE REQUESTED: 5 <br /> COMMENTS: y/�Q u PAYM <br /> RECEIVED <br /> U 2004 <br /> Y(J SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> / EALTH DEPARTMENT <br /> APPROVED BY: EMPLOYEE#: (� DATE: <br /> ASSIGNED TO: ^ EMPLOYEE#: S DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: 6 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-502 <br />