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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR Al ns-o MuviO CHECK If BILLING ADDRESS <br /> FACILITY NAME 5WM rk, q--1 lAC1A-i-e, <br /> SITE ADDRESS 1 23 P�L1 M L1 5 <br /> Street Numbe Dfroction ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number t at Name <br /> CITY Vl, !t4 ,, �� STATE CA zip ^ 5- 490 0 <br /> N <br /> PHONE#1 W� `� EXT, AP # LAND USE APPLICATION# (/I <br /> ��I1N 2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR ^ <br /> I I' 1 cam. t f,Lyll CHECK If BILLING ADDRESS <br /> BUSINESS NAME !J'` ^'�O�tl�� P 0 xT' <br /> rf1rl/ -I-1/ G IACD I <br /> HOME Or MAILING ADDRESS FAX# <br /> f ) <br /> Cm STATE 04 <br /> zip 01 <br /> �7 <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 /> 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 FEDERAL laws. ��f ^1 <br /> APPLICANT'S SIGNATURE: }� ��O✓1& Uhf Z <br /> G � i <br /> DATE: o I 'J� <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> IfAPPL1CANT is not the B//diNG PAK7Y 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 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. L <br /> TYPE OF SERVICE REQUESTED: nO PICA <br /> COMMENTS: <br /> fitCO fiWCl4- IPWI5 . SFp 7V4$6 <br /> 3p <br /> HN�Y,MVror���ry <br /> ACCEPTED BY: EMPLOYEE#: DATE: 0it <br /> ASSIGNED TO: , • v��Yi EMPLOYEE#: DATE: V <br /> Date Service Completed (If already completed): SERVICE CODE: 5�3 PIE: <br /> 114101 <br /> Fee Amount: 4r` +5 V D Amount Pai s6, ,)v Payment Date C 2-0 <br /> Payment Type Invoice It Check# qq-T ecehied By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />