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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> M �' L f C) O'�ac\a� ::A sl�L�)0 <br /> O NER/OPERATOR <br /> ( _5 l �- 1 a� La_ I CHECK if BILLING ADDRESS <br /> FACILIrY AME lJ (� <br /> 0) o 109 <br /> SITE ADDRESS _ / a� ?" k xCI�t n5j 46 <br /> �X^ Street Number DiracStreet Name <br /> ZI Cotle <br /> HOME' AI^ /,7d <br /> or MAILING ADDRESS (If Different from Site Address) � ; LpnSln4- <br /> YW Street Number Y�orl�m�T+ � }}-- Street_ Namen �� � J <br /> CITY STATE ZIP <br /> CL(I 1 NG C:�/I <br /> PHONE#t ExT' APN# LAND USE APPLICATION# ' <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQU TOR <br /> CHECK If BILLING ADDRESS <br /> BUSfNESS NAME -j''' II _ PHONE# ExT <br /> (. U ' &26— <br /> HOME or MAILIN AgDRESS FAX# <br /> 4 0 L 4- �{n <br /> CITY /I I STATE ZIP n /� <br /> BILLING ACKNOWLEDGEMENT: 1, 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 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, STAT a d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: *4, A,4� DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ /--ISS/ ' -:5QC 2&9— <br /> IfAPPL/CANT 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and agme time it is <br /> provided to me or my representative. " II��♦•®o <br /> TYPE OF SERVICE REQUESTED: O �-L --b n <br /> COMMENTS: S�JOA �? ?019 t <br /> EN QL/N <br /> Hit H p0p� A4 tY <br /> 71 <br /> ACCEPTED BY: 1 IM 1 EMPLOYEE#: DATE: I I"ZO-I <br /> ASSIGNED TO: / Mh - EMPLOYEE#: DATE: <br /> Date Service Completed (if a ready completed): SERVICE CODE: P 1 E: h ou, <br /> Fee Amount: 4102. Amount Pai Payment Date // <br /> Payment Type 41_` Invoice# Check# /jj93 p2V13 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />