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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S R <br /> o0ot 13(60 <br /> OWNER I OPERATOR HECK If BILLING ADDRESS❑ <br /> Q t�5� Ad I l-, :� C✓Ll �1 JIM/1 t,�t✓3'--� <br /> FACILITY NAME Men do-:Z-ii 5 C1,44-, cap C ' <br /> SITE ADDRESS 2—L-H 0 S J�1�[]"yJ� �` t / 1_�� Zu. <br /> Street Number Dlraetlon /` , 7`•'—Street Nama 7 �T� city ZI Coe <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2�� `� kir lJ <br /> Street Number Street Name <br /> CITY i-t STATE M ZIP 9j (�.z <br /> PHONE#1 EaT• APN# LAND USE APPLICATION# - / L <br /> c2�-1 > cl 2Z ^ 3512 <br /> PHONE#2 _ En. BOS DISTRICT LOCATION CODE <br /> (' ) 2-L <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Q05� ��(� A �y�,�/� � r/I `1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME "er '(V/1� S C,em Y 1(A <br /> Q0511 <br /> /` y�V Y v P^ <br /> HOME or MAILING ADDRES'2-0,,, �Pl4 l� ��'���(/ FAT# L <br /> VK ( 1 /} <br /> CITY STATE ZIP t/t� 7 <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:1( __ ,: DATE; <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> tfAPPLICANT 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 5 (ime it IS <br /> provided to me or my representative. M <br /> TYPE OF SERVICE REQUESTED: �V COMMENTS: <br /> 3 70 <br /> ,'AfdOgQU/N 7 <br /> H <br /> 7-110 <br /> Df�N HT <br /> ACCEPTED BY: �, kA EMPLOYEE#: DATE: <br /> ASSIGNED TO: F EMPLOYEE M ,( DATE: V <br /> Date Service Completed (if already completed): SERVICE CODE: I y () PIE <br /> Fee Amount: 4c�Z Amount Paid I V7� Qr Payment Date 2 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48.02.025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />