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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �ROz�N YoG-R-- Shve z3�z� a <br /> ::A <br /> OWNER OPERATOR <br /> �U.4 A✓6-Q UO U�(N�- CHECK It BILLING ADDRESS <br /> FACILITY NAMEM��Gt4l�S <br /> SITE ADDRESS 7 E Z 4 LAJ 5?E I ZC <br /> Street Number Direction Street Na.o-- city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Stmt Number Street Nam <br /> Cm S A * TA KoSA <br /> STATE <br /> TCR- Y IS L16 It <br /> PHONE#1 �' APN# LAND USE APPLICATION# <br /> (707 1 88$ "g7Fs(t <br /> PHONE#2 E`T BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR Ca IrA4- If BILUNe ADDREss❑ <br /> l a N Fpd <br /> BUSINESS NAME AA„e�L�t tS I 1_ PHONE# G -7 LE j <br /> HOME or MAILING ADDRESS ^ ; �Fa6 <br /> /t 3 q FAX III <br /> o S `T <br /> CITY r_. N1_ �JS a, STATE C.11 21P 7s—xf <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 /> 1 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,Standard $TATE d FEDERAL aws. ��UC,,�I <br /> APPLICANT'S SIGNATURE/: �`� o P DATE: << A cz/Lv z U <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> JlAPPLicdArris not the BILLING PAR 7y 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 SERVICE REQUESTED: N e-CA) U L'/' CCX <br /> COMMENTS: <br /> Is <br /> N417T��� <br /> qR T•q� ry <br /> ACCEPTED BY: C2 hrK`O,S Ge, EMPLOYEE#: DATE: ^(T <br /> ASSIGNED TO: T�!, - EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 0Z <br /> Fee Amount: l Amount Paid ISS,UD Payment Date <br /> Payment Type i Stii I Invoice# Check# f/70S3 7` Red ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17t2003 <br />