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SAN JOAQUL -OUNTY ENVIRONMENTAL HEALTH -,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i <br /> c�(D <br /> OWNER I OPERATOR/]//((JJ��"ttj <br /> /�) �Ir' CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME ;2O Q PqFe <br /> S /,tQY y� •�./�Y/ Jay,, /� <br /> SITEADDRESS 60r) •�DirectioTo(--+ <br /> OC- or '(/•,t•- (-- <br /> Street Number CV%Ak Vee Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different fr m Site AddreSS) <br /> / I J 6— d Street Number Street Name <br /> r CITY U� I STATE ZIP qe5—rj L LO <br /> PHON #f EaT• APN# LAND USE APPLICATION# <br /> (`t 1 ) �6 y- �J 2 <br /> PHONE#2 E�• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME 6 ; P11I9NE#, T• <br /> HOME or MAILING ADDRESS <br /> CITY ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the L 60-v-'- authorized agent of same, <br /> acknowledge that all site and/or project specific - associated with this project <br /> or activity will be billed to me or my business as. n ( QW <br /> I also certify that I have prepared this application a ° + nce with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AI <br /> 1jAPPLICANT is not the BfLLlNG PARTY Title <br /> AUTHORIZATION TO RELEASE INFORMATIC -operty located at the <br /> above site address, hereby authorize the release of : Cotyjy{ <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENI It tR¢sa e ting ,I� <br /> provided to me or my representative. _ RE �V LJ <br /> TYPE OF SERVICE REQUESTED: 'i�cloj ALIG 1 0 )� <br /> COMMENTS: (� <br /> GNGtIACY ()1 JtMQ(!� SAN JOAQUIN COUNTY <br /> d` 'I ENVIRONMENTAL <br /> HEALTH DEPARTME14T <br /> ACCEPTED BY: EMPLOYEE#: DATE: LO- 2A l <br /> ASSIGNEDTO: VA EMPLOYEE#: DATE: L <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> Fee Amount: (�2 Amount Paid 5 Z Payment Date 2-v2-I <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Q�2 Otlp 2(n�10 <br />