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t i <br /> r- <br /> S.43N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT C j 0 9 2014 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 1 <br /> L HEA TH <br /> O 'CRARITMENT <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME �Vim �Y1 ��c��-•�vlY�' /t 1 <br /> WE ADDRESS .•J' l <br /> Stroet Number Dir�Ion i' Slrort e G 2i Cotle <br /> ROME or MAILING ADDRESS of Different from Site Address) <br /> Street Number St Name ' <br /> CITY STATE zip <br /> PHONE#1 Err. APN t LAND USE APPUGATIO?1 ft <br /> -,dog f 1 <br /> PHONE#2 EXT. F75��7 <br /> LOCATION CODE <br /> I <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR `� CHECK If BILLING ADDRESS <br /> e6Ly_-vqh(A'r+- <br /> BU$IhESS NAME �Q l) !_ ` -f 19e� ��jT V'C/�-S PHONEEXT. <br /> HOME orMAIUNGADDRESS � ,FAX# <br /> g .S- <br /> CITY STATE C ZIP 1 S3 <br /> J.J <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of some, <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 FID [ laws. <br /> APPLICANT'S SIGNATURE: D..kTE: <br /> PROPERTY/BUSINESS OWNER❑ PERATORIMOTuERAUTHORIZEDAGENT� 04 tfa <br /> IfAPPLICANT is not the BILLLYG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORIMATION: 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 environrnentalisite 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. y <br /> TYPE OF SERVICE REQUESTED: P}� !1}1 e 1 l�- �- r f <br /> COMMENTS: <br /> i <br /> l <br /> i <br /> ACCEFTFID BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE N: DATE: <br /> Date Service Completed (it already completed): SERVICE CODE: P I E: <br /> 1 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORPA(Golder Rod) <br /> REVISED 11/1712003 <br /> £Z'd £9699V960Z wnelo4edalgeile2l eLO:£0t'160300 <br />