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• ni. vivo 1-11vnv vnvnnruv ,..v vvc.,vvv <br /> SAN JOCOUNTY ENVIRONMENTAL HEAL&REA,RTMIENT <br /> SERVICE REQUEST <br /> /yp®of Busims or Properly FACILITY 10 0 SERVICE fgfgQUEST# <br /> Ll' Dred 1q'gd 1l F'4 00 / -Z-3/ 0 <br /> OWNER lI OPERATER¢� <br /> h'Rdloc�i�tze� CHECK irgEM❑ <br /> Facartr NAME <br /> &rO rw isex _of 101: 2 <br /> SITE ADDRESS K /`' 7fjrAPlkc. �� Sk�or✓f 7`7 <br /> t Number DI Sweet Name Cft <br /> HOME or MAILINGADmitEss (N Different from Site Address) <br /> CITY STATE ZIP <br /> PNONEl11 Ext. APN0 /75= /70 Af 4WIf IANDUsEAPPucATION# <br /> t ) /7S /90 t7! <br /> PHONER ExT• BOSDIBMCT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUE570R <br /> CHECK if BILLING AQQ&W <br /> CIL <br /> BUSDtESS NAME/r p s tC(� <br /> /� <br /> HOME Or MARINGZ�RO 02 ork �1 v/6i AA, 15 (I yA 67Y-21,00 <br /> CRY STATE ZIP G? <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> ac1mowledgc 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,STAUan4 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER TOR/MANAGER❑ OTHER AUTHORIZED AGENT❑ <br /> 1f.4PPLJCANT Lr n the LIN PARTY proof of authorization to sign is required T.No <br /> AUTHORIZATION M 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 av the same time it is <br /> provided to me or my representative. pL"�� <br /> TYPE OF SERVICE REQUESTED: <br /> CotwaT t,,�,vl ' o-5 4 &% � {v.S1-�.�t r , (�j ,o c ) JUN <br /> G0uNN <br /> 'm1751 � iu�itatla�wi S t,°� cobt' gAeNVRpp1pRt4N <br /> ACCEPTED BY: EMPLOYEE#: VC1 DATE: O <br /> AssiGNED To: y EMPLOYEE#: f DATE: <br /> Date Service Completed (if already completed): SEImcE CODE: 0 P f E: (�� <br /> Foe Amount: Amount Paid Payment Date / 0 L <br /> Payment Type Invoice# Chock# �tf a, L_ Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />