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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property I /� FACILITY ID# SERVICE REQUEST# <br /> 2Vrt AV }-A VI <br /> k,06 f 1CJ )FXI �l� ?i �O W wt' 1 g l <br /> OWNER/OPERATOR <br /> CHECK It BILLING ADDRESS E] <br /> VL-e/ <br /> FACILITY NAME <br /> TAn4�y�m ynIGe-fiq E%- UIVIe*'D <br /> SITE ADDRESS �p33 <br /> O) E �A )tet 2U �� �r 5-Z is <br /> Street Number Direction 77 Street Name City Zip Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY �� STATE ZIP <br /> 01 CA <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> ('SL O) (P O(1 2,(-p 09 <br /> PHONE ICI EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> KLke,A, R So,vLC eZ CHECK IfBILLING ADDRESS� <br /> BUSINESS NAME PHONE# ExT. <br /> a Vl-I&M A1/f' i LXV1oi ElL &GAVIC/it'llb s to Ce 0(o -2AQO I <br /> HOMEor MARLINGADDRESS FAX# <br /> LAI Li ( ) <br /> CITY fir STA ZIP qtA <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL aws. <br /> APPLICANT'S SIGNATURE: P�Pj/'1 '4' ' /ke DATE: — 2 3— <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tl7�l�yple time it IS <br /> provided to me or my representative. . F <br /> TYPE OF SERVICE REQUESTED: '"�P C l n mz;-1A ' J('�J6�� �� <br /> COMMENTS: ?g <br /> ooH'ytiFc 0019 <br /> PpgRq7Y <br /> ACCEPTED BY: 1 u.n A , n EMPLOYEE#: DATE: p) •�// tat <br /> ASSIGNED TO: J R �/� EMPLOYEE#: DATE: v <br /> Date Service Completed (if already completed): SERVICE CODE: ` PIE: I <br /> Fee Amount: .I�Z. coAmount Pai Jra. �� Payment Date y3 <br /> Payment Type 6:;16 k' Invoice# Check# `Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />