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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> :::] p�\Wl-t-\ 2g LLQ <br /> OWNER I OPERATOR !�EKU : , <br /> (] �O✓1 i-1- / CHECK If BILLING ADDRE55E] <br /> FACILITY NAME�("\(,��,•I0 <br /> SITE ADDRES 952,o3 V <br /> lsereee Numbor Direction Street Name Cit ZI Cotla <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY TO I\„r© 'V STATE /^ ZIP <br /> (HONE#1 1 EM• APN# LAND USE APPLICATION# <br /> PHONE#2 6 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I CHECK If BILLING ADDRESS <br /> BUSINESS NAME G Q /— 1®\©�(I�� P 5NE <br /> HOME or MAILING ADDRESS' 1 J �• FAX(AX# ) �}r <br /> CITY �("© IL• � I I !_ STATE ZIP qy 2 <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 /> XAPPLICANT'S SIGNATURE: 1 ;r cote DATE: 0 40 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN AG R ❑ OTHER AUTHORIZED AGENT <br /> IfAPPLICANT 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 REQUESTED: <br /> COMMENTS: •11G 3 !1 <br /> q , V <br /> CO <br /> """" nlf <br /> ACCEPTED BY: O v N\n EMPLOYEE#: DATE: <br /> ASSIGNED TO: l\ 1 `` EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): Vs L SERVICE CODE: O PIE: <br /> \�O� <br /> Fee Amount: \52, Amount Paid Payment Date <br /> Payment Type Invoice# Check#r Received By: <br /> v <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> ��.o5�13g3'I <br />