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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ResTiawL }-�14 <br />FACILITY 10 # <br />WbOW <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />"f'Hm m j I.4,0 t rk, <br />//11 <br />Se ZIF S J b <br />CITY ` J ` <br />CHECK If BILLING ADDRESS❑ <br />FAdurY NA7 ,t VM /-?,r 1 pit il k, P'-L•L�}� <br />`, 1 �` r N f _ ` f ") <br />(jo <br />SITE ��DYRaE��Ss <br />�/'v1 Ireal,um0er <br />Direclbn <br />W�-s <br />IM,1'/y, <br />e ,,Na� <br />�t <br />I ` , <br />` <br />� ( <br />Pfi ✓" <br />"i <br />S 66 <br />_'�e�° <br />HOIM�E1or MAILING ADDR 55 [(If DiRergnt from Site Address) <br />0s) m I ee W <br />y - �%�f <br />'/gyp/ .1r_ <br />SlneagGmEor <br />Slreel Na a <br />CITY <br />�(//�1 <br />$ip7E <br />ZI <br />PHONE #1 <br />(Zpf) o?4-3Dd3 <br />APNR <br />Fee Amount: 5a ' <br />LAND USE APPLICATION# <br />PHONE#2 E^. <br />BOS DISTRICT <br />2 <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK If BILLING ADDRESS 13 <br />BUSINESS NAME Mo L44,1 rW' �IV� <br />HoMEor MAIL A,DV ESS 1 C� <br />Y.! J <br />Full I <br />//11 <br />Se ZIF S J b <br />CITY ` J ` <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 ENviRONMEM'AL 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 prepared10E <br />ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY ordinance Codes, Standan . ERAL laws. G/ <br />APPLICANT'S SIGNATURE: DATE: I •y�� / <br />PROPERTY/BUSINESS OWNER�R/MANAGER❑ OTHER AUTHORIZED AGENT❑ JIGh <br />JjAPPLICANT is not the BILLING PARn'. proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 asre�rlt� <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTas soon as it is available and at th <br />provided to me or my representative. jaj;rr-tVFD <br />TYPE OF SERVICE REQUESTED: <br />COYMENTSi <br />Q� © <br />U/ <br />�S <br />(jo <br />DEC 14 t <br />SAN JOAQUIN C <br />EMJIRONME <br />HEALTH DEPAR <br />ACCEPTED BY: <br />EMPLOYEE 111: <br />'7 <br />DATE: ' f <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE' `L <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: ! (]y <br />Fee Amount: 5a ' <br />Amount Paid <br />Payment Date <br />2 <br />Payment Type S <br />Invoice It <br />Check # <br />Received By: <br />Cop,( 4 136V2127Z <br />EHD 49-02-025 SRF M (Golden Rod <br />REVISED 111172DO3 <br />)L1 <br />IUNIY <br />TAL <br />MENT <br />