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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 /> AA/ ?fY„ / Me�Q�h� <br /> FACILITY NAME {�t�/ ✓� CHECK If BILLING ADDRESS <br /> 0AA0 Ur-w/ 4jI?J LL dL2 <br /> SITE ADDRESS /ls'V C(j Gam/V/E IZ �520�- <br /> 300 Street Number Direction L Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ext. APN# LAND USE APPLICATION# <br /> (xJ ) y51— X5y <br /> PHONE#2 ExT. RQC n!$TR!„T L^CAT!ON CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 2 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> M 0 fl i S Ott/ 6r2!LL 6 F-4R ( —3900 Or MAILING ADDRESS FAX# <br /> Q 2 ( ) <br /> CITY �Z 'v SATE ZIP ZO 2 <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, STATE and FEDERAL laws. 2 / <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER [0 OTHER AUTHORIZED AGENT❑ <br /> YAPPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br /> AbCvC S::e .:ddrec„S, here-by aut1:0 T.L t!-.c rdicaso of any and all results, :ain and!or L ironn—enter-1/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: bnotv- A <br /> COMMENTS: <br /> M ce)�FO <br /> sq,y�ogR 11 <br /> hFFNv,qov <br /> 44 0NMFco <br /> ACCEPTED BY: EMPLOYEE#: DAT TM 60 <br /> ASSIGNED TO: EMPLOYEE#: 3 DATE: l0 <br /> Date Service Co leted (if already completed): SERVICE CODE: • P 1 E: `W—Q <br /> Fee Amount: 5Z (�) j Amount Pai l s� O'D Payment Date 3 �1 20 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />