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SAN JOAQUL .OUNTY ENVIRONMENTAL HEALTI LPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY . . <br />It <br />ID # <br />00 2-03 <br />- SERVICE REQUEST # <br />Coq -7 (0 b ? NUlt) Pee cur facA <br />OWNER / OPERATOR <br />Izoqex -tiw-ti <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />-b O) eAf ard -f\-v-t-ofYla6ve Styv‘ce <br />SITE ADDRESS 21 5 I <br />Street Number Direction <br />.ovvrt-iij nulo i3oulevarot <br />Street Name <br />ci 52 014 <br />Zip Code <br />SIto c4(ton <br />City <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />P0 17)0)L IGI lo 2. Street Number Street Name <br />CITYLA. cul_L-46- STATE apt ZIP <br />ci5-710 <br />PHONE #1 Exr. <br />22) '''' \'j00 <br />APN # <br />12-5 - OVO - 50 <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR tick.o .i.e t \J1(( cull ueva. <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME hovo,nced Geofrivirovionm A Ct-rxl I . PHONA <br /> <br />EXT. E <br />(2-C) 14 (0 -1 -100‘.0 / <br />How or MAILING ADDRESS el yi ‘fl avy \zo cAck FAX # arch Liol- in <br />CITY siocy...ton STATE Cois ZIP 6115 21 S. <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 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. <br />APPLICANT'S SIGNATURE: <br />DATE: <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: 6,0- <br />COMMENTS: <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: P I E: <br />Fee Amount: Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />PROPERTY / BUSINESS OWNER D OPERATOR! MANAGER 0 <br /> <br />OTHER AUTHORIZED AUTHORIZED AGENT 181 SGA,W <br />If .4 APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003