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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i=/61 (DO 2-LA-9-5 I S`Q- 00 S21 <br /> OWNER/OPERATOR S \/A A 2 {2P m►QP CHECK If BILLING ADDRESS <br /> FACILITY NAME j C/n C I.. R V1 1 I `� F(,Li -2S, <br /> SITE ADDRESS `( •J S (/ �l �1� iaq v <br /> Street Number Direction treet Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ?� S . w' I SUy-1 Wim,/ Ari C <br /> Street Number Street Name <br /> CITY _ ` STATE CA ZIP 61 S2 0� <br /> PHONE#t �Iv EXT APN# LAND USE APPLICATION# <br /> (2o°I ) 3qo - sL(li 3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR VV�`I <br /> 1�/^/'Y L) t2 n r-lA /)I y ! CHECK if BILLING ADDRESS <br /> BUSINESS NAME LA tAChC4✓li 1 <br /> 1 e-, � � 7 `l/ I2-SC) P1 1 36 S� EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> 1.3 23 S lJ ' 1 5G-V1 W C ( ) <br /> CITY SwIri <br /> STATE e A ZIP 7, <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> APPLICANT'S SIGNATURE: t��j���li�p /I,��i/�E Z DATE: O Z /,,;,C) <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 PAyhrt,is <br /> provided to me or my representative. . <br /> TYPE OF SERVICE REQUESTED: v �1l 1 V` C/k U--l <br /> COMMENTS: j) I Q �03 <br /> V"S k-IP SAN JOAQUIN <br /> IENVIRONM <br /> CplN <br /> HF-A'7-"D PARTME <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P1 E: 1(4P63 <br /> Fee Amount: Amount Pai / "'? ,nom Payment Date / Z� <br /> Payment Type r.� Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />