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II <br /> I ' <br /> t- <br /> ' LLM i <br /> g'y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 10 P ERATOR <br /> V CHECK if BILLING ADDRESS <br /> a <br /> FACILITY NAME <br /> SITE ADDRESS $C�2 v Ll +�^• �l 71P <br /> d <br /> Street Number Direction Street Name Ci ZI Cade <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> O• Bo)( 2" <br /> Street Number Street Name <br /> CITYTE zip <br /> atom i n -�-on (A <br /> PHONE#1 EXT. ApN 9 LAND UsEAPPLICAT101U# � <br /> I zc4i) 093`4SU " d <br /> PHONE#2T• BOS DISTRICT LOCAs N CODE <br /> { 11 <br /> _4 <br /> CONTRACTOR/ SERVICE REQUESTOR rp <br /> �. <br /> REQUESTOR CHECK if BILLING } � �a�,� <br /> �. <br /> BUSINESS NAME <br /> PHONE# EXT r <br /> 0" UY-Pl�r-[. _ 0 334-�.1013 <br /> HOME or MAILING ADDRESS FAx# =7 � <br /> P.D• O Z1TCG dl,t f { 133 X713. <br /> f <br /> CITYr r^CSS aTE/+�4ht ZIP rn <br /> t LCL- sk r <br /> BILLING ACKNOWLIDGIi er, operator or authorized agent of same <br /> acknowledge that all site and/o '� ` "�P� t' IT hourly charges associated with this protect F <br /> or activity will be billed to me i sk <br /> I also certify that I have prepar, I be done in accordance with all SAN JoaQvnv <br /> COUNTY Ordinance Codes,Sta � w <br /> APPLICANT'S SIGNATURIQj <br /> DATE' <br /> PROPERTY/BUSINESS OWN ER❑ )AGENT 9d SVI-Vb,r-.< <br /> If APPLICANT is w •equired <br /> AUTHORIZATION TO RE] ier or operator of the property located at the <br /> above site address, hereby a u-+ti c-- S G- V aE data and/or environmental/site assessment <br /> information to the SAN JoAQui / t oon as it is available and at the sarrie time tt Isf ; <br /> i provided to me or my represen r ms <br /> TYPE OF SERVICE REQUESTED: -)4-77 C3,lj <br /> COMMENTS: PAYMEN-CY <br /> RECEIVED 3 <br /> .SUN 1 0 200$ <br /> SAN JOAQUIN COUNTY i y <br /> ACCEPTED BY: EMPLOYEE#: EPH <br /> ASSIGNED TO: s Ge�`l`Z� EMPLOYEE#: yr DATE: <br /> Date Service Completed (if already completed): SERVICECODE: PIE: 2� <br /> Fee Amount. Amount Paid L ` IL, 0-0 Payment Date (mI S C 0 <br /> Payment Type ✓ Invoice# Check# 33� Received By: <br /> EHD 48-02-025 5R FORM(Golden Rod) <br /> REVISED 11117/2003 <br />