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1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> O NE (OPERATOR <br /> // n�N r• CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITEADDRESS �.�SS L �(�,ZQ't n Sdo� .(QVL gS 20 <br /> Street Number Direction ' 1� Street Name �CIJ 21 Code <br /> HOME Or MAIUNG ADDRESS (If Different from Site Address) ZZs -y' <br /> $ 'F <br /> Street Number Street Name <br /> CITY CJM/ /1� STATE ZIP <br /> Py <br /> APN# LAND USE APPLICATION# <br /> P ONE#2 <br /> EXT. BOS DISTRICT LOCATION CODE t <br /> b <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ' ^� AtCA' Y t A & Ch <br /> fL✓ rC/r CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1= 3.3 - -73 35 EXT. <br /> HOMEorIMAILIG AslOR1E-S�1 ,1 I1v.�0, ' _ FAX#-102- <br /> CITY STATE <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> 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. <br /> APPLICANT'S SIGNATURE: Jach.cy 0 h yl -'Aj DATE: -3 /U'I /O1 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 11 OTHER AUTHORIZED AGENT 13lk <br /> if APPLICANT IS Ot 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is wvided to me or <br /> my representative. ����JJ r� A <br /> TYPE OF SERVICE REQUESTED: i l.a, PIVt✓1 C 10&k- <br /> COMMENTS: <br /> 0&kCOMMENTS: Mgrf <br /> fv� �c HQ <br /> 019 <br /> /y,EioU/9tyNVti <br /> )Y <br /> ACCEPTEDBY: MPLOYEE#: DATE: 3 t to <br /> ASSIGNED TO: V �IQ(t/� EMPLOYEE#: DATE: I� <br /> Date Service Completed (if already Completed): SERVICE CODE: S'Z� PIE: I��1 <br /> Fee Amount: L � Amount Pai 4�,OD Payment Date / <br /> Payment Type Invoice# Check#ys3/4 N Re eived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />