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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OP RATOR <br /> c'lvr�G� <br /> FACILITY NAME '` CHECK IfBILLING ADDRESS❑ <br /> U !``/' �o <br /> E �Glrtrp 1 <br /> SITE ADDRESS�~�� <br /> J rK� <br /> Street Number eet a treet ame Cft Zi Code <br /> HOME Or MAULING ADDRESS (If Different from Site Address) <br /> 3-3-1 /ql del - r Street Number SIreet Name <br /> CITYSTATE ZIP <br /> Y`a c C-/4 C75 3 1/ <br /> PHONE#t EXT- APN# LAND USE APPLICATION# <br /> ( y)6 ) '�C--�L --00140 <br /> PHONE#2 EXT- BOS DISTRICT--71 LOCATION CODE <br /> { ] <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTQR <br /> u -,-I <br /> LQ 0T I. CHECK if BILLING ADDRESS <br /> �1 <br /> BuslNEss NAME £ U EQ A-k I � PH�z# EXT. <br /> �;� ,�—b'1do <br /> HOME or MAILING ADDRESS FAX# <br /> J P1 c ) <br /> CITY T�„aC ST T ZIP`71—T37/ <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 /> 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: J a�� DATE: /Vo-?/- .k"q <br /> PROPERTY I BUSINESS OWNERK OPERATOR/MANAGER 13OTHER AUTHORIZED AGEN'r❑ <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 HEAL-ri-i 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; I IJ <br /> COMMENTS: Qc �� Eo <br /> y��Ro�,N�o ozo <br /> rye pMENT�N�Y <br /> �RTMFNr <br /> ACCEPTED BY: Owl EMPLOYEE##: DATE: I �� <br /> ASSIGNED TO: 0 { , EMPLOYEE##: DATE: <br /> Date Service Completed (if already completed): SERVICE COLE �, PIE: !' <br /> Fee Amount: 4(c G— Amount Pai4P Payment Date I LAZO <br /> Payment Type ` Invoice# Check# ,J5.39'27 R ceiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ��f1 [ 1 I„52 <br />