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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# 7540 '85ct <br /> VICE REQUEST# <br /> tes-r-t�� f- ;9 ,�� 4a <br /> OWNER OPERATOR <br /> CHECK If BILLING ADDRESS <br /> CILITY NAME <br /> vL <br /> SITEADDRESS Zz 8 Z. YO.I e 1-7 t TY / *1JTeC 4 X1533 6 <br /> Street Number Direction Street Name city Me Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ezr. APN# LAND USE APPLICATION# <br /> (Zell) gzs-- L( 3s <br /> PHONE#2 Exr• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> PHONE# Ex . <br /> BUSINESS NAME /A ���/ v ,C/ Z9 O p ZS-� : <br /> HOME or MAILING ADDRESS FAX# <br /> Z- <br /> CITUA,j (�.�t/�� G STATE ,1 ZIP 3 G <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 ERAL S. <br /> APPLICANT'S SIGNATU L DATE; �G -Z Z Z <br /> > /J > <br /> PROPERTY/BUSINESS OWNER El M ❑OPERATOR OTHER AUTHORIZED AGENT /{A eydt 7-4-w I <br /> If APPLICANT is not the B!/.LI/YQ PARTY,proof of authorization to Sign 7S required T',1, <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/W' assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the4 Vs4k* A�IS <br /> provided to me or my representative. R e•�" <br /> TYPE OF SERVICE REQUESTED: cT/ owat-4L'ja , 17rr <br /> COMMENTS: ty ,?42y <br /> SgN SOA <br /> � <br /> NFA( RONMF OuNJY 1)6q M NT <br /> ACCEPTED BY: r u e C O EMPLOYEE#: 04(jo 7 DATE. I O ;Z r✓ ,g a <br /> ASSIGNED TO: ?-d h m EMPLOYEE#: Oo <br /> > S' S <br /> O DATE: IO a s a.^oI <br /> Date Service Completed (if already completed): SERVICE CODE:O l 6 O PIE: 06 <br /> Fee Amount: l S Amount Paid �Sco U� Payment Date / � 2— <br /> Payment <br /> Payment TypeI(_ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />