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} <br /> R <br /> SAN JOAQU, . COUNTY ENVIRONMENTAL HEALTH --PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Pro e / FACILITY ID# SERVICE REQUEST# <br /> /QitNt 'SU�� �/-7 <br /> OWNER/OPERATOR <br /> ^ " CHECK If BILLING ADDRESS <br /> 017 iaO od <br /> FACILITY NAME W1 /�v0� (,(�/ -s <br /> SITE ADDRESS .5,r,r e lywo o D r <br /> 11 Street Number Direction Street Name Ci Zi Code <br /> et Nu be, FDie.ft. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> P %. h&LOA ^ Street Number Street Name <br /> CITY STATE ZIP <br /> 9,Po,J C.4— <br /> PHONE#I EXT. APN# 0 3 ( -00/ LAND USE APPLICATION# <br /> �9 ► 3 5�5�— ��s'" i 4100. D�lvo 3b� <br /> PHONE#2 EXT. .,,.i:.ir�i_ BOSDISTRICT LOCATIONCODE f� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR s <br /> CHECK If BILLING ADDRESS <br /> !rV I <br /> BUSINESS NAME PHONE# Exr. <br /> HOME or MAILING AD RESS FAx# <br /> D A STATE CA <br /> ` ZIP <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,ST <br /> APPLICANT'S SIGNATU _DATE: 6 Z 3 aJ <br /> PROPERTY/BUSINESS OWNER OPER AGER ED AUTHORIZED AGENT❑ �(( .Grlip ,Gt. <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirte <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: Li u( f r) C v,4 4,LcG(C- L E TM�e - <br /> COMMENTS: P�tic..s.t �rrr,�aa.rd 1 F6" Dv�►a1a'N• <br /> 7??C,4,,rt�J ks Ca�Mam s <br /> Cttc u �� PEC IE.V �o <br /> l4(s-� �► R SZZ ,W-4 11 CAJ11 1W �1 S82S <br /> AIrt E(AI J*.V-ACS <br /> ACCE �(�j?j OUN EMPLOYEE#: �;1 1 DATE: 0 �/L� <br /> ( 5 ccs sus— <br /> ASSH SAN MENT <br /> C ) S(oS-�lt"o.?k' NVIFGN EMPLOYEE > YS Z DATE: <br /> tEAU TL --TP <br /> 1 2E:Date etedSERVICE CODE: t <br /> Fee 1 5 L Amount Paid (o Payment Date (o S <br /> Payment Type Invoice# Check# �Z�8 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />