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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> c�o��c�I�' YXV+1 <br /> OWNER/OPERATOR <br /> '1 `t,l CHECK If BILLING ADDRESS <br /> oc <br /> FACILITY NAME Kms. YV u rTeo <br /> SITE ADDRESS ) 1\A � t vW/aeGa � G, <br /> '1',f Street Number Direction h Straat Nam CI Zip Code- <br /> HOME or MAILING ADDRESS (If Different from Site Address) G hp pT A\J Q �e p' <br /> OStreet Number ! ` — Strreatt Name <br /> CITY f t 0&5io SATE ZIP C./ <br /> /i� <br /> PHONE#1 <br /> EXT. APN# LAND USE APPLICATION# <br /> (Z _ I4_4 If <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR '�U7�Vt` �y) <br /> Q,Uor-- 00 CHECK If BILLING ADDRESS <br /> BUSINESS NAMED �p� PHONE# S I — ` EXT. <br /> 11 I4F <br /> HOME Or MAILING ADD ES$ r, 1e (FAX# ) 6 <br /> CITY � (L�� V T TE ZIP <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 /> 1 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 F ERAL Ia <br /> APPLICANT'S SIGNATURE: DATE: D � <br /> —PROPERTY/BUSINESS OWNERIaIyOPERATOR/MANAGER ❑ OTHER AUTHORIzED AGENT❑ <br /> I,ffAPPLICANT is not the BILLING PAR 7Y 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. <br /> TYPE OF SERVICE REQUESTED: TWO CMIA 140h OA <br /> COMMENTS: 1,�CJI `Cl IrI�Q� 0AytDIGFp8� <br /> � <br /> TD <br /> Nroq ?020 <br /> NvW/6T/ ONM, "OUiv <br /> ry <br /> ACCEPTED BY: 1 /I�j� C, EMPLOYEE M DATE: C/ <br /> ASSIGNED TO: v l r e 1 lJ EMPLOYEE M DATE: ' OOY <br /> Date Service Completed (if already completed): SERVICE CODE: 131 <br /> Fee Amount: 5/L'� Amount Paid �.S Payment Date 8/ 2 jj <br /> Payment Type le!t Invoice# Check# P 2-71 ?Z3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 51-41/ I^ S <br />