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0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> R ET N I L. F -Z3Z� S 2 o d S 10 t Z- <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> V k V- S Z' h WA N-(Z IG&-C-< - <br /> FACILITY NAME ^ r , (� T.O P * 13 2-- <br /> SITE ADDRESS �G V p 0A P% 2 S TO C!C TO�f c� S-z c c( <br /> 3 S Street Number Direction Street Name Zi Code <br /> HOME or MAILING ADDRESS (if Different from Site Address)) <br /> 115-t, ^+ E W1 E P-P rt% 5 k- '&'T- - Street Number Street Name <br /> CITY 2�VUk 0+1LT STATE A ZIP �� g <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (TIO ) 6 s} - T S-0 0 <br /> PHONE R EXT. BOS DISTRICT LOCATION COD <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR '^, ' C J A �� f I (. CHECK if BILLING ADDRESS <br /> !1+Y tel/ PHONE# Ems' <br /> BuSINESSNAME A L-r' �lt (iLuc,E�2t�C�, �r4 C• t6 3 3 - t ( S 2— <br /> HOME or MAILING ADDRESS FAX# <br /> P . (0 . 0 )(. <br /> CITY i 1 - C` -� STATE (:7 ZIP '? S-/_ a <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 anj that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S A and F DERAL laws <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT® B U-�R .4-CA-V <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 DEPART as soon as it is availablethe same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: -P C C ' C k s P E C-t o <br /> U <br /> COMMENTS: ��/�, 6, <br /> V/ <br /> i <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: TO V A. A-NL �� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E 2 <br /> Fee Amount: Amount Paid a L-y:�> Paymen ate <br /> Payment Type Invoice# Check# ceived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />