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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CE REQUEST # <br />r <br />OWNER/ OPERATOR - <br />I<� i �'Ac1/� � /'„^p <br />Vll• Il/ <br />CHECK If BILLING ADDRESS El <br />I4 <br />FACILITY NAMEiC�/�}' �I (tt ✓� ��1 <br />/ <br />ST L(�P 1. G <br />A10 <br />gQWAI <br />SITE ADDRESS i d <br />Street umber <br />I Direction <br />PI et2 cc AV`2 <br />I me <br />At <br />Ma✓I�ricn <br />city <br />EMPLOYEE #: <br />X15 <br />Cotle <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />1P \ <br />1 t�reemF' <br />1•e <br />CITY ry n <br />V` G <br />STATE ZIP <br />PI E: O <br />PHONE f ExT. <br />APN# <br />Payment Date <br />LAND USE APPLICATION <br />Payment Type a4 <br />PHONE # Exr. <br />ec I <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />kA (1 , Ve /!1 V-WyCHECK If BILLING ADDRESS <br />BUSINESS NAME <br />e4i �SACImn ?,i1ptfp <br />PHONE# Ezr.Ii <br />31 2J 17 <br />,f2 <br />HOME or MAILING ADDRESSln I3 ,.I� �/► <br />��r(� �'t� <br />�,CC <br />(Ax# ) <br />CITY <br />M <br />molklecp Alstp <br />/ <br />ST L(�P 1. G <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 ENvtRONMENTAL 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 laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tile <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: -F150 <br />pq <br />COMMENTS: �' ^ r, , „r, e O �i ”, , I, , rt �! } _ �-t <br />cL►,�� <br />O <br />"!J(,' <br />202(J <br />A10 <br />gQWAI <br />Nj <br />'Y4 7-, <br />At <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />�V <br />ASSIGNED TO:VU <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: I <br />PI E: O <br />Fee Amount:14 152 <br />Amount Paid [ h a � <br />Payment Date <br />Payment Type a4 <br />Invoice # <br />I <br />ec I <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />