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SAN JOAQt,uQ COUNTY ENVIRONMENTAL HEALl—DEPARTMENT <br /> SERVICE REQUEST <br /> Type o Bus ine s or Prop rt FACILITY ID# SERVICE REQUEST# <br /> i 0C�?I Z�F ;KO�0 ^ 3`� <br /> OWNER I OPERATOR -- <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAMEa( l 11 oui, C4neSS <br /> SITEADDRESS au '^ wan6c <br /> d Street Number Oirectl¢n A/V1 Street Name cIt 2i Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> ( 1 ZZ3 ,0Zo r6 <br /> PHONE42 Ezi. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> Sdw funs <br /> HOME or MAILING ADDRESS FAx# <br /> �a ( ) <br /> CITY 4eQSCAVJ6Px CA STATE ZIP sS a <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 ENv[RoNNmNTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to we 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, STATE and EDERAL law �- <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINEss OWNER❑ OPERATOR/MANAGER ❑ OTHER AHTHORIZED AGENT❑ <br /> 1fAPPLTCANT is not the B1LLTNGPARTP 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. nwcp� <br /> I'AY <br /> TYPE OF SERVICE REQUESTED: 0*, .C� ,Y+c�tlT <br /> COMMENTS: D <br /> APR 3 0 2014 <br /> SA ENV R UINq�Nry <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: O DATE: J! I .s# / <br /> r �7 <br /> ASSIGNED TO: EMPLOYEE#: y 3G �p DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: ?>�C)-?- <br /> Fee <br /> -?-Fee Amount: Z O mount Pai /oZS QD Payment Date 3() <br /> Payment Type Invoice# Check# 3��1'7 Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />