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L ' . SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 4 SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3 Ll '15 b )k <br /> OWNFR OPERATO <br /> 7/1/ CHECK If BILLING ADDRESS <br /> FACILITY NAM ' <br /> o's re axot <br /> n� <br /> SITE ADDRESS `('t'a" Cl� Vls , W <br /> 129 emkil Street Number1. DirectionStreet Name 1 CIt Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 22-Le Sami t Street Number Street Name <br /> CITY Q. . T C 33 STATE ZIP <br /> PHONE#1 ET. APN# LAND USE APPLICATION# <br /> (2�1) 1,oy0-99 tv4 <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 /> 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 Im s. <br /> APPLICANT'S SIGNATURE: (g DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAC W 61 OTHER AUTHORIZED AGENT❑ <br /> IfAPPL/CANT 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 t0 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: '� 0/1 Mie <br /> COMMENTS: vi <br /> OCT 02 <br /> SAN OgQUIN42O20 <br /> p H47710F�M� <br /> ACCEPTED BY: 1 a' n /7 EMPLOYEE#: DATE: O <br /> ASSIGNED TO: EMPLOYEE#: DATE: 2 <br /> Date Service Completed (if already completed): SERVICE CODE: D P 1 E: / n <br /> Fee Amount: Amount Paid P Payment Date I ; <br /> Payment Type AIn�v�oiicce# f I /� Check# Received By: 1 <br /> EHD SED 11/1 Ilp�a,ry�'. l 1 L-Y f/I 1 n 7-+� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 v`� �" I - 6(� <br />