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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �.,4 -ZgI SQm <br /> OWNER/OPERATOR Ra <br /> I'( t CHECK If BILLING ADDRESS <br /> FACILITY NAME / <br /> VL OI <br /> SITE ADDRESS ',Z,4,IO J �I�h wAr t,20 �'y[kY on col• <br /> 22107 Street Number Direction Street Name Cil Zi Cotle <br /> HOME Or MAILING ADDRESS (If Different <br /> from Site Address) <br /> 6 3 8 S • r Street Number Street Name <br /> CITY STATE zip <br /> Manfelct t?t- L75-33 7 <br /> PHONE#'I EXT' APN# LAND USE APPLICATION# <br /> ( 9M) 4!8 S 3 7 a 5' <br /> i —] <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /r / CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXr. <br /> -� /l n} p,\ (ap Qjq 9Y 3 7 qj <br /> HOME or MAILIN�G/ADDRESS FAX# <br /> 63S n n R�1 ( ) <br /> CITY L_ &-- STATE ZIP 1? 7 3 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, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: , ( $�— <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PAR 7Y 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 availeq �a�N�a time it is <br /> provided to me or my representative. M <br /> TYPE OF SERVICE REQUESTED: •{� v'Qj�/l( — �t p <br /> O <br /> COMMENTS: /t a _� OCT L 202 <br /> Il rl,Jli�' II`�l`r�� SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY:Ivvx� EMPLOYEE M DATE: <br /> ASSIGNEDTO: 1,Q, EMPLOYEE#: DATE: �Y <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: i <br /> Fee Amount: tL Amount Paid tfC l 5- 2 Payment Date Zjp <br /> Payment Type Invoice# Check# Received <br /> EHD 5 ��153/ Iy SR FORM(Golden Rod) <br /> REVISEDSED 111 11/17/2003 <br />