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(E ho, <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTM NT <br /> SERVICE REQUEST !C2 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2eSVtnUCU n 1: S 2 <br /> OWNER i OPERATOR <br /> ' haM SI C-D A•�5 CHECK If BILLING ADDRESS <br /> FACILITY NAME F S <br /> Vac �_w 0o�rs5-{ r��}, Ips 1 G <br /> SRA D9REO (2-O �SC0. IC l / 320 <br /> Street NumNer Direction Street ame CI ZI Cotla <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ( 5-to) ?-g7 t-20L <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( 5 f()) �(L(27? L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' <br /> / <br /> (I 10c CHECK If BILLING ADDRESS <br /> BUSINESS NAME1 r PHONE# En. <br /> .w00C'$ .L�' C - 'tCSS c N ZZZl <br /> HOME Or MAITG ? ESS <br /> ESS / / FAX# <br /> �L 2 1 (� i !/�.U 1 1 ) <br /> CITY 5cq (04 STATE (:�J ZIP �3Li7 <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 iq accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA and <br /> APPLICANT'S SIGNATURE: {/,%v DATE: ( 1 I 1-7 0 <br /> PROPERTY/BUSINESS OWNERIi]� OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> If�APPLICANTisnotthe BiLLINGPARTV proofofauthorization 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. I• ' r <br /> TYPE OF SERVICE REQUESTED: yno6 C J\ Oy-\ PA1'M <br /> COMMENTS: E /s <br /> SEP b 120% <br /> a"EyJ yAQ IN Co <br /> �dlT9f® ME/N,TA� <br /> ACCEPTED BYEMPLOYEE#: DATE: <br /> ASSIGNED TO: r EMPLOYEE#: DATE: <br /> a'. <br /> Date Service Completed (if already completed): SERVICE CODE: ` 1 1 E: <br /> Fee Amount: (S Amount Paid f 1601 Payment Date 6LI20 <br /> Payment Type Invoice# Check# Received By: <br /> r <br /> EHD 48-02-025r ., ( SR FORM(Golden Rod) <br /> REVISED 11/17/2003 V i <br /> �I°ol�3�aLI' <br />