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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT SERVICE REQUEST Type of Business or Property FACILITY ID # SERVICE REQUEST # BUSINESS NAME r PHONE #' ASSIGNEDTO: ��r �a'c GL�! ixYi.r n- c_ HOME Or MAILING ADDRESS /S/O O OWNER / OPERATOR _ CHECK if BILLING ADDRESS FACILITY NAME CITY �� (%� % /' STATE SITE ADDRESS ZIP q'`• 'a? C!>iee/4G lln4fJy✓le!D Payment Date Payment Type -z:F77 Street Number Received By: Street Name city Zip Code HOME or MAILING ADDRESS (If Different from Site Address) ' C !�gUpe /9/0 Street Number Street Name STATE ew ZIP L�SaU S CITY �� Lg—e ;-,g/ PHONE #1 ExT• APN # LAND USE APPLICATION # (209 ) 2 53 -0-? o --i PHONexT. (1�6— /7X o BOS DISTRICTLoTION J � CONTRACTOR / SERVICE REQUESTOR REQUESTOR/,/L COMMENTS: AL? ILL //✓�/�� E�/H llrr.� �� yZ�/� �5//�E�% ! �v.7�� /`7� rC ��/.�%L LIQ% / v/- 3 /✓EL✓ �iW.'•/✓OG✓/'F"l�'�c"/Q /� `!//' / J ��/✓/' %�Gc'�1 //✓ �i4-r• - % /�i`�' ✓1 ,Q%�„i-� !� i✓,'� y ,v vi�;.y j✓�-•T � /ir�7�/J� ��l l%?�' :%7��' G�i'✓lir� CHECKifBILuNGADDRESS■' BUSINESS NAME r PHONE #' ASSIGNEDTO: ��r �a'c GL�! ixYi.r n- c_ HOME Or MAILING ADDRESS /S/O O (-74') C74" 7 p. 607 CITY �� (%� % /' STATE �� ZIP q'`• 'a? BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDE aw . APPLICANT'S SIGNATURE: DATE:/ ZO/i PROPERTY/ BUSINESS OWNER❑ OPERATOR/MAMA R ❑ OTHER AUTHORIZED AGEN'l' If APPLICANT is not the BILLING PARTY proof of authorization to sign is require AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. TYPE OF SERVICED REQUESTED:�r,EGL �1�lGL/i✓�/�E� COMMENTS: AL? ILL //✓�/�� E�/H llrr.� �� yZ�/� �5//�E�% ! �v.7�� /`7� rC ��/.�%L LIQ% / v/- 3 /✓EL✓ �iW.'•/✓OG✓/'F"l�'�c"/Q /� `!//' / J ��/✓/' %�Gc'�1 //✓ �i4-r• - % /�i`�' ✓1 ,Q%�„i-� !� i✓,'� y ,v vi�;.y j✓�-•T � /ir�7�/J� ��l l%?�' :%7��' G�i'✓lir� ACCEPTED BY: 14,44%411 '.� eC { �O "f y r �!-is` a�C, EMPLOYEE #: !/ 4i' fs J DATE: ASSIGNEDTO: ��r �a'c GL�! ixYi.r n- c_ EMPLOYEE#: DATE: Date Service Completed (if already completed): SERVICE CODE: ._ ,c7/ } PIE: t-/ y0 % Fee Amount:) , Amount Paid Payment Date Payment Type Invoice # Check # Received By: EHD4802-025 L�LZ/i2 _ G�Erz-=N��"•• ryc /�r�L - f� ihr��e!• y� c_� /;1��r� z.�r J - REVISED 1 111 7/2003 212.1112 - /Llc S Citi= f. r i6'/ ty - / I /l ?y J �z •• n r, l t� «c�c ...�� -- �12'/ -,Ie lux" - /I4 �/ry/t z j//S // 2 LAG"i cr %'-J�u•� f � [ct` /G�iyc .....�" i L< =i /1 � r> �l,..y:,c,. i _S- -f - AJ SR FORM (Golden Rod) 4 -J ��i� 7✓�