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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r,jq Ll 5S Sft© 2' <br /> OWNER//;OPERATO2R, / ( �]�`y. - <br /> M Vt rl D 1 U�e`Ip "P�/L e T " ,,' 6,�p CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> /1 T ( o <br /> Loc_()v <br /> _ C <br /> SITEADDRESS a C/(fp 'r�� r1-{—i"t (�(� �'S�C l� <br /> Street Numher Direction Stre¢t Name Cit Zip Code <br /> HOM�Or,,�M,,A,)IL�I�NG ADDRESS (if Different from Site Address) <br /> CS�'em'+"r.u' S T G L� Street Number Street Name <br /> CITY Cl STATE ZIP <br /> qC'tbr 0 sz C) <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#Z Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME I� PHONE# ExT. <br /> [ cLrJ <br /> Lo Lo y ro�-I13� <br /> HOME or MAILING ADDRESS FAx# <br /> 1r12_rlt� L-Ad 0- ( ) <br /> CITY \` '' y, STATE G ZIP <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, STAT d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: - j - Zo r✓o <br /> PROPERTY/BUSINESS OWNER❑ OPERAT /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 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 SERVICER �Adoi,FNT it S <br /> COMMENTS: RECEIVED <br /> NOV 12 210020 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: UA WO WO EMPLOYEE#: O DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: Dlr PIE: <br /> O <br /> Fee Amount: ' ou Amount Paid-/? d� Payment Date <br /> Payment Type Invoice# Check# / Received By: <br /> EHD SED 11/1 � o ^ "j I I SR FORM(Golden Rods <br /> REVISED 11/17/2003 YI,Il`V/��-( J"' <br />