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,l ��s+���d/1iV� ���y;7►�wA.Tr�.=4�! "�� • ���x•t���1'�•- •im'KS`K�YRh....w.IM•aYMr1WTi�aP..YiKi.•/ '- �L♦ x y <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT h <br /> SERVICE REQUEST <br /> Type of Business or Property _ l FACILITY ID# SERVICE REQ §T�# , <br /> VE V1 U M <br /> DO 1�514 <br /> OWNER 1 OPERATOR CHECK If BILLING ADDRESS❑ i <br /> V,� IC R S1-t FooD INC, <br /> ' <br /> FACILITY NAME <br /> SITE`ArD�DRESS OII :IHO NE MOP-PW) LAN C- <br /> -1 <br /> I oCK`�t1N � SZ{2 <br /> `1y StmetNurnber D tr a Name CI ZI Gado <br /> HOMES or MAILING ADDRESS (It Different from Slte Address _ <br /> 2 `�S � I RA \ero�,t,A CUV�� Suvet Number L StreetName <br /> CITY C3—\ 0 C`14-7 O N STATE CA, <br /> ZIP q(�?-O 9 <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (z �ellg <br /> F <br /> PtiO)!E } EXT. BOS.DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ j <br /> BUSINESS NAME PHONE# EXT. i <br /> HOME or MAILING ADDRESS FAX# f <br /> i <br /> ( 1 ir <br /> CITY STATE zip <br /> r <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> t <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 /> Y <br /> I also certify that I have prepared this application and th t rk to be performed will be done in accordance with all SAN JOAQUIN I <br /> COUNTY Ordinance Codes,Standards,STATE and FED at <br /> APPLICANT'S SIGNATURE: DATE: //''�� rr��� i <br /> PROPERTY/BUSINESS OWNER in OPERATOR/MANAGER ❑ OTHER ALITHORIZrD AGE.,-r❑ [--Jw�C'�Z V <br /> JfAPPLICANT 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 <br /> COMMENTS:rr%C E.1V ED <br /> RE Y (Ana ojt C. (�vA el s1�� P <br /> AN X2421 <br /> SAN d0A UIN COU <br /> LS + <br /> ACCEPTEW Q. EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M10 4 <br /> DATE: [+ <br /> Date Service Completed (If already completed): SERVICE CODE: ' PIE: <br /> �DZ <br /> Fee Amount: 2 Amount Paid Payment Date <br /> Payment Type Invoice# Check# I Rece ed 13y; <br /> EHD 49-02-025 SR FORM Golden Rad) ' <br /> REVISED 11t17i2003 { <br />