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SAN JOAQUIN ,—JUNTY ENVIRONMENTAL HEALTH I —_ ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 L45 ( -[ <br /> OWNER 1 OPERATOR <br /> il„ _ /I *5-3 S� <br /> FACILITY NAME 2-V +�L CHECK if BILLING ADDRESS <br /> l I+V�SS �j�� 'Wr <br /> SITE ADDRESS 1010 NCCr,2eo-- /�ift4N1 p� - <br /> �J �l 95336 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 9PAY <br /> Street Number Street Name CITY STATE ZIPPHONE#1 EXT• APN# LAND USE APPLICATION# 0(2M ) gz.S-41W I sq,,, 18 Z�19 <br /> PHONE#2 EXT 1[BOS DISTRICT LOC O(f <br /> ( } CTiy a NMS T�1Y <br /> CONTRACTOR 1 SERVICE REQUESTOR M�nrr <br /> REQUESTOR <br /> fL CNECK If BILLING ADDRESS <br /> BUSINESS NAME i PHONE# EXT, <br /> t op,6 dbt g s'P .S / - 767 3-27-Y75-6 <br /> HOME or MAILING ADDRESS FAx# <br /> 73 k G tJ ( ?(97) YY9 :379? <br /> V <br /> CITY im/1Vt`Le ` STATE zip 9E6.9& <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 /> 1 also certify that I have prepared this application and that the work to be erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE.and I p <br /> APPLICANT'S SIGNATURE: DATE: t?—30 <br /> PROPEWIFY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 19 C0M')R--7 1L1 <br /> IfAPPLICANT 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 SERVICE REQUESTED: �-S { ST-4— n <br /> COMMENTS: "2 <br /> FA <br /> LL. <br /> �W/►9B/cvG C44 P G9-S 6 R-- ll�c c.�L Cl ti ar3 -VrP� <br /> ACCEPTED BY: ` S G� EMPLOYEE#: DATE: lf +d e <br /> ASSIGNED TO: 1 u iii_ EMPLOYEE#: DATE: }0 d`[ <br /> Date Service Completed (if already completed): SERVICE CODE: S-Z3 PIE: <br /> 1 <br /> Fee Amount: 2�a ,� Amount Pai 3d d� Payment Date �� l <br /> Payment Type CK Invoice# Check# �S(aG Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />