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NAJ\1 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST 0 <br /> School <br /> OWNER/OPERATOR I ( L <br /> QSan Joa �Ih COI A L/n rye [Mix / -hoc CHECK B BILLING ADDREaS� <br /> FACILITY NAME -n(D C 1� Va l�. ou rl , r-a l �I UL r/, �L <br /> SITEADDRESS �-rvYlS'0JJ�� 1N �Aovei p ^VNO iJ r7�nii2 y�7/„ <br /> SMMt Numtrr DI Ame 1 Cos. rJ <br /> HOME Of MAILING ADDRESS IN DNfemnt from Site Addram)1J.O. BOA Z 130 Q S�Nom <br /> Strwt Number <br /> CITY ^ STATE op ZIP /�S^ I� <br /> PHONE#1 ETT. APNe LAND USE APPLICATION a -/ G <br /> ( ) V4• q27 <br /> PHONE92 E*T BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /'n <br /> S hQ✓){�O� SV I 'A n o CHECK N BILLING ADORESa� <br /> BuawEse NAPESAvl Joaquin CANT 06te p(r QG�t(q f 1W PHONE# <br /> 2aq yes- 279 <br /> HOME or MAILING ADDRESS FA%# <br /> P0 god 21 3a3O (?,79' ) <br /> CITY S /'. .L+..r'J STATE C,*- Z!P <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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 la S. <br /> APPLICANT'S SIGNATURE: ` ! / DATE: D 1112,1) <br /> PROPERTY/BUSINESS OWN ER 13 /�—J OPERATOR/MANA ❑ OTHER AUTHORIZED AGENT I� �Mo✓ d.,,fg 0-sT.-'t. <br /> IjAPPLICANT is not the BILL/NG PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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 environmentat/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. `j <br /> TYPE OF SERVICE REQUESTED: LC <br /> COMMENTS: C <br /> OFA o O <br /> HE /vT R0/ 0 <br /> 0�N�Y <br /> `I R <br /> ACCEPTED BY: KL EMPLOYEE M DATE: T <br /> ASSIGNED TO: L IEMPLOYEE*: DATE: <br /> Date Service Completed INalrmdycompleted): SERMCECODE: ()(o PIE: <br /> Fee Amount: ��,2,OLS Amount Paid SZ, Payment Date 3 <br /> Payment Type CK Invoice# Check 0 /b 759 Recelwd By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 <br /> QR-o5�"93� S <br />