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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SR00g q 3qq <br /> OWNER/OPERATpR ^ ID I �� <br /> l./ ( 5 /YIV �1\OCHECK if BILLING ADDRESS <br /> FACILITY NAME -E / L'�\ V d` _�� <br /> SITE ADDRESSS `'] <br /> 1�2 ' / Street Number Directions 6��Y Street Name ' " Cit Zip Code <br /> OME or MAILING ADDRESS If Different from Site Address) <br /> '�JJ... <br /> 'S©� `-n-� �"A \0�u k�AStreel Number Street Name <br /> CITY STATE„ ZIP t <br /> —�`(-� � C T-I C:I 5 � <br /> PHONE#t En, APN# LAND USE APPLICATION It <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Lu 13 I v 1 1�1 <br /> � �`i `1^ �� CHECK if BILLING ADDRESS <br /> BUSINESS NAME .� I\ V` PHONE# ExT. <br /> Q 1 Li— O V O lC� O ( L(--C- <br /> HOME <br /> L_L 2 / <br /> HOME or MAILING ADDRES§ FAX# <br /> r,2- I L-1 35 <br /> CITY A— STATE c✓A ZIP 9330L—) <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 1 have prepared this application d t t he work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,Sr TE a DERAL aws. <br /> APPLICANT'S SIGNATURE: DATE: O <br /> PROPERTY/BUSINESS OWN ER OPE AGER ❑ 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. I- <br /> TYPE OF SERVICE REQUESTED: VC k 1C15n_ <br /> COMMENTS: •yCO <br /> Pan Cvuc(C ocr,? -c <br /> h �0% �O? <br /> T,H <br /> ACCEPTED BY: N./ EMPLOYEE M DATE: ) 'Z <br /> ASSIGNED TO: 'J EMPLOYEE DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: WC <br /> Fee Amount: ; (�L��.� Amount Paid j,T](7o Payment Date I b <br /> Payment Type Invoice# Chec✓k## Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod)/ <br /> REVISED 11/1712003 <br /> ( It-, <br />