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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> S , �I ! CHECK If BILLING ADDRESS E] <br /> FACILITY NAME �1 �� / t uby k M 0-f C— <br /> I. <br /> - <br /> SITE ADDRES/S1(`� L ,/�G,� Ve <br /> `I Street Number Irectlon r Street Name /tel Clt ZI Cotle <br /> HOME or MAILING AD RESS (If Diff rent from Site Address) <br /> 2 C Street Number 1 � {reote <br /> CITY ,� to �jI STATE ZIP <br /> (/� 9S 2 <br /> PHONE#1 V EZT. APN# LAND USE APPLICATION# <br /> (zc,ry ) X77- 3CP22 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 2o9) - S5G <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t e CHECK if BILLING ADDRESS <br /> BUSINESS NAMEnn PHONE# EXT. <br /> AW'0\V L1t 0 IADY 6ve (2o9 ) 2- -7-7- 2 <br /> HOMEor MAILING ADDR SS /I rte- FAX# <br /> 2 - c C ( ) <br /> CITY { STATE ZIP S(K <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 wor:to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Colles,Standards, STATE anFEDERAL laws p <br /> _APPLICANT'S SIGNATURE: P �Sn DATE: O O — z(O — ,t] <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT 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 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: W' con'SW v/} R �� <br /> COMMENTS: , <br /> ALIG 1 <br /> Chall5re Gf OWnew-gh,iP o s20 <br /> H F�R� �O 2p <br /> 2 �� Oep �� <br /> ACCEPTED BY: / /I'�1 I�/71 EMPLOYEE M � o DATE: <br /> ASSIGNED TO: CV�1 tit EMPLOYEE#: ✓ DATE: 2(� <br /> Date Service Completed (if already completed): SERVICE CODE: P E: <br /> Fee Amount: (� Amount Paid S� v Payment Date S2Z <br /> Payment Type Invoice# Check# :�/, Received By <br /> EHD 48-02-025 / / �OL4�i� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 , <br /> (ld Yvt <br />