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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> >`A ooZ.GLyL. s� �o�s3 <br /> OWNER/OPERATOR 1 C_ n eS CHECK 9 RILLING ADDRESS❑ <br /> m <br /> FAcILNAME .�. IV•"•v�[_�1V <br /> SITE ADDRESS 4,1 S, l�t /�� ®, %in r/O� 9rj g$c <br /> ciw <br /> Zip Coft <br /> HOME or MAILING ADDRESS (Ir D nt o he ddress) n I ,U <br /> �A I ei( r <br /> 5 Number <br /> �Pt <br /> s 30 7 <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> ')Cot' 769-79L/7 <br /> PNONE#2 Eu. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQOESTr(' CHECK NBILLINe ADDRESSO <br /> BUSINESS NAMEF( `Q j�l .� PHONE# <br /> En. <br /> HOME or LING ADD SS !U r FA%# <br /> ( ) <br /> CITY STATE ZAP Jr 3 0. 7 <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 orf armed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F O ORAL I s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BusTNEssOwNEa OPERAT AGER ❑ OTHER AuTuoRrzeD AGENT❑ <br /> 7fAPPLICAN7 is not the BILLING PAnrT 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 sa�siiple it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: t B� <br /> COMMENTS: <br /> J0.1 QO�20 <br /> Ht /R NM COON <br /> HOBagTy <br /> eMN <br /> ACCEPTED BY: ,� EMPLOYEE DATE: <br /> ASSIGNED TO: — EMPLOYEE#: DATE: <br /> Data Service Completed IN already completed): SERVICE CODE: Vtol PIE: N A4 <br /> Fee Amount: Amount Paid Sa 0 Payment Date <br /> Payment Type Invoice# Check# I I gqt�)D-7 0 Re'oel d By: <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> t <br /> �10 p,I,{U3 22 S <br />