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SAN JOAQUAUNTY ENVIRONMENTAL HEALTHOARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />L_ A -r4 12 s 'jam E. c, T--( o4 <br />FACILITY ID # <br />SERVICE REQUEST # <br />R,E�7A,IL C-VE.L <br />PHONE# <br />9/6 <br />% <br />riqcolQ® %/ <br />Se0o L4 -7L7--7 <br />OWNER / OPERATOR <br />FAX # <br />(gr6 <br />QU t (L S -ro tp M A N K � ' S , JK `. ` CHECK If BILLING ADDRESS <br />FACILITY NAME ^ O W � - r�OT <br />l` 7 <br />S L <br />SITE ADDRESS <br />s, <br />C ®k ( t! l� - <br />L Q <br />�l s L g 0 <br />Z t Street Number <br />Direction <br />Street Name <br />Ci <br />Zi Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />µrt [- rL -P )-LL <br />' <br />`7 S 6 � <br />Street Number <br />Street Name <br />CITY f� f?-, r- VIA 01,L .- <br />STATE C A ZIP A 3 g <br />PHONE #1 EXT. <br />APN#©� <br />LAND USE APPLICATION # <br />(S'r0 ) - 8So0 <br />(o s -- <br />,,(( <br />2-��1 <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 1 C (,i- A e t- VV N L -r0 , ^t t <br />L_ A -r4 12 s 'jam E. c, T--( o4 <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />LA/AL11 0tk E r(�.t►cEk-rt_t14C., SQLC- <br />PHONE# <br />9/6 <br />ExT' <br />34-3 - II V-�- <br />HOME Or MAILING ADDRESS <br />'12. O• Box /02.5- <br />` <br />EMPLOYEE #: /n <br />111✓✓✓✓ <br />FAX # <br />(gr6 <br />L('4-z_ <br />CITY ', I ES T- c A, -O 2 A v. I, 0 <br />STATE C A <br />ZIP 9.s- 6 a t <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 a d that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards,STATE an EDEM/I--- <br />APPLICANT'S SIGNATURE: DATE: 'f O <br />PROPERTY / BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT C 0 ""r IZ ,A-cJT—O rt____ <br />If APPLICANT is not 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 <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. QAVI\,1�1i\JT <br />TYPE OF SERVICE REQUESTED: <br />L_ A -r4 12 s 'jam E. c, T--( o4 <br />R rE CE- I VE D <br />COMMENTS: <br />^ U G 2 52006 f1 0 C <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />` <br />EMPLOYEE #: /n <br />111✓✓✓✓ <br />DATE: <br />ASSIGNED TO: <br />l <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): S Rv10E CODE: <br />P / E: 2-:92)S <br />Fee Amount: <br />Amount Paid IT <br />Payment Date <br />a-5 C) to <br />Payment Type <br />Invoice # <br />Check # 3 (o, 1 ! <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />