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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> QS TS'011♦ion /C- S*re FA 00I501 R S Cj�O <br /> OWNER/OPERATOR <br /> Noe Pkclytc <br /> Vic. <br /> ' CHECK If BILLINGADDRESSE] <br /> FACILITY NAME Th i4 Ober I j,/v` <br /> SITE ADDRESS �K.r�T(G } Sfia�c.t�b'.J 9�r2O <br /> t� Street Number Direalon S f reef Nam✓ee cityZI Code <br /> NOME orMAILIN DDRESS (If Different from Site Address) ' `9 <br /> 1 Street Number Street Name <br /> CITY /� • STATE zip <br /> O&CfAOYOQO <br /> PHONE#1 ✓�rJL ERT APN# LAND USE APPLICATION# <br /> (logo <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( 1 �So rpN 55W — <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR.7nOC <br /> /f • •C <br /> BUSINESS NAME CHECK If BILLING ADDRESS <br /> ✓ PNO E# EXT. <br /> ^�,.• � D '• <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITYSao • ATE ZIP IYo t( <br /> BILLING ACKNOWLEDGEM : 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 withthisproject <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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 SIGNATUr �RRE:� d "h DATE: vV 20 <br /> PROPERTY/BUSINESS OWNERLJ OPERATOR/MANAGER ❑C/ OTHER AUTHORIzEDAGENT❑ <br /> IfAPPLICANT 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 same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> SAN Alli l p 2010 <br /> tV <br /> /RO�b (�D�oL� g �4--Ijc) 0 y� CO <br /> A THOENR T1VMEAfM/ <br /> ACCEPTED BY: I I A EMPLOYEE#: V DATE: ''L Ail <br /> ASSIGNED TO: `r vy _ EMPLOYEE#: ZI DATE: I 9-0 <br /> Date Service Completed (if already completed): SERVICE CODE: /D Ph: 2 <br /> Fee Amount: Amount Pai �S�,oa Payment Dat <br /> Payment Type Invoice# Check# I QGt Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />