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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE <br /> REQUEST (�� <br /> Type of Business or Property FACILI � �SER�/ I�S ST# <br /> 7OWNER/OPERATOR IIL /ff/I G� CHECK If BILLING ADDRESS <br /> FACILITY NAME nt �f � I�W�/lM ' A nt AI <br /> on <br /> SITE ADDRESS r-12 I-� (l� I L <br /> S[ree[Number Direction Street Name CI ZI Code <br /> HOME or MAILINQ ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY (��I /),n �c/, ST TE ZIP //3� <br /> PHONE#'I I_l t/t� I W E APN# LAND USE APPLICATION# t� <br /> (�) W q 0 3q <br /> PHONE#2 EZT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR -� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEE�vu^� t /1.[� PH�E# Z' y/ �y EZT. <br /> HOME or MAILING ADDRESS -U ((� FAA# <br /> 2 ,4;S-o,0 ST ( I <br /> CITY M 4.10 -. STATE, n_ zip 5�-S-330 <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, �TATES. / <br /> APPLICANT'S SIGNATURE: DATE: y 3 ZI <br /> PROPERTY/BUSINESS OWNER❑ OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT 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 saltie time it Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: D,/ <br /> COMMENTS: �� -emA,mIV?` <br /> SFp 0 C VFO <br /> 3 <br /> 20�RN4p MC 2� <br /> ACCEPTED BY: M `(-� S, EMPLOYEE#: a DATE: FN <br /> ASSIGNED TO: 6 wI b// EMPLOYEE#: 33/v/ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O/ / P I E: ��D <br /> Fee Amoun . /sa a�D Amount Pat Sa, �� PaymenttPDate 2/ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Quw-1 c�� <br />