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SAN JOAQUIN evNTY ENVIRONMENTAL HEALTH DWTMENT <br />. SERVICE REQUEST <br />Type of B iness or Property <br />LI �� T <br />FACILITY ID # <br />BUSINESS NAME C ^� C_ 1 <br />Jae o1 � StCk°{(C* A J tC S <br />SERVICE REQUEST # <br />!4� SYPkTICt.� <br />jj ExT. <br />Z(S �- lE o 3 F <br />3 <br />,Cj" `�" 4i <br />OWNER / OPERATOR <br />CITY ^rCi,t.l <br />CHECK If BILLING ADDRESS D <br />`• � CAI <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: 2 <br />Amount_Paid T)2-71 z)D <br />I Payment Date <br />FACILITYNAME <br />Invoice # <br />Check # '--Xt l <br />SITE ADDRESS ,-las - <br />1'iY <br />I <br />`Trcl�cy 3lrrd <br />� � <br />'7 <br />9 S3 �l o <br />Street Number <br />Direction <br />Street Name <br />Ci <br />zipCode <br />HOME or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE zip <br />PHONE #i ExT. <br />APN # <br />LAND USE APPLICATION # <br />(.:Zo) ` t <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />M c►.� t 11�e�.�fl.vr�a"�-1 <br />BILLING <br />LI �� T <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME C ^� C_ 1 <br />Jae o1 � StCk°{(C* A J tC S <br />rqvc" YC.uS OITSSP �NVP <br />PHONE# <br />q6 <br />jj ExT. <br />Z(S �- lE o 3 F <br />HOME or MAILING ADDRESS <br />(p�6V <br />FAX # <br />ASSIGNED TO: <br />CITY ^rCi,t.l <br />STATE TQ <br />zip 5711;;1— <br />711 <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. <br />-(�r &iln%itc�b(suls. <br />APPLICANT'S SIGNATURE: lytL , ' u. „t L t i, c �-r DATE: �i,�'.• ' j{ 3 � �`C� ' <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT �•K[hl I +` I . l J T4� a <br />If APPLICANT is not the BILLnvGPAR7I proof of authorization to sign is require--� Ti Ch(q <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the N'( <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site asses �p <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the sameY0 �S1v <br />Drovided to me or my representative. _ 1) <br />TYPE OF SERVICE REQUESTED: <br />LI �� T <br />SPR <br />COMMENTS:�gS `tV GlA'� -+ J 3 I " Q• <br />rqvc" YC.uS OITSSP �NVP <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: O <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />Fee Amount: 2 <br />Amount_Paid T)2-71 z)D <br />I Payment Date <br />Payment Type <br />Invoice # <br />Check # '--Xt l <br />I <br />I R ceived By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />