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.- SAN JOAQUIP )UNTY ENVIRONMENTAL HEALTH PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# FSER—VICEREQIUEST# <br /> 7L(' —V <br /> OWNER/OPERATOR r 7� ESS{LY <br /> �y <br /> S� Gt'M��L � , 1 ' ( ��M CHECK if BILLING ADDR <br /> FACILITY NAME U <br /> 7 <br /> SITE <br /> E� RE d /w�I e 1� y�_�C�1��'(-2 I� ✓ �vl Ai L ZI S� <br /> Y Street Number Direction Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 I/1 - L4") g-�gU APN# LAND USE APPLICATION# <br /> (,�09) g _2 - .7/S <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> {,. �lvo CHECK if BILLING ADDRESS E] <br /> BUSINESS NAME �L PHONE# EXT. <br /> l 140 Q i �� dos-/S37 <br /> HOME or MauNMAD DR S I Fax# ) �� - <br /> `// <br /> 4 <br /> CITY ` `�� STATE (;19 <br /> zip 6s 5- 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 DEPART {'IPhourly 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 pgtvill be 4one in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <\J' <br /> (� <br /> APPLICANT'S SIGNATURE: �' ,. ,�/�_ n%ti\N'PXT 141— <br /> . <br /> J' `/ <br /> . — cc N _ �"0tplAo�E _, <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHAN%; iN 1�)fI�T <br /> If APPLICANT is not the BILLING PARTY,proof of authorizatioi*Qn 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. <br /> TYPE OF SERVICE REQUESTED: <br /> /vr 0 <br /> COMMENTS: /Vl/0(f7� � U/!C S n17 k& pZ "' t p-yv6i,,-t <br /> ACCEPTED BY: In/1, Nay/1 �� EMPLOYEE#: DATE: L 1 Gj / 3 <br /> ASSIGNED TO: / EMPLOYEE#: DATE: 'l I <br /> Date Service Completed (if already completed): SERVICE CODE: r (� O P 1 E: Z 3 r"o <br /> Fee Amount: .315- <br /> 15 _ Amount Paid *3-7s o-D Payment Date Lf3 <br /> Payment Type ✓ Invoice# Check# Re ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />