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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property =�� rr��_FACILIT//Yl ID# SERVICE REQUEST# <br /> v��W)u <br /> OWNER I OPERATOR <br /> e` O!h�� CHECK If BILLING ADDRESS <br /> FACILITY NAME ` l 1 <br /> �Kt? Chi vv'o <br /> SITE ADDRESS \a\I 1� • -1 kA S'{'-' kA U oI-P r'-1-a q <br /> Street Number I Direction I Street Name city Zip Coda <br /> HOME or MAILING <br /> �ING ADDRESS (If Different from <br /> �Site tAddress) l <br /> "Je? G�UF-- U-2 Street Number Street Name <br /> CITY 1'UOS+ID STATE C44 ZIP <br /> PHONE#1 1 v T APN# LAND USE APPLICATION It I /) <br /> *L)`I) 116 SI - I`1 U� <br /> PHONE#2 ETr• BOS DISTRICT LOCATION CODE <br /> i--8u`+O <br /> / SERVICE REQUESTOR <br /> REQUESTOR <br /> Y�Ic�-e1 /c���G � CHECK If BILLINGAODRESSO <br /> Tvte <br /> BUSINESS NAME ��// PHONE# Exr. <br />- Churro �P°�- ao SS-1-l�0� <br /> HOME or MAILING ADDRESS FAX# <br /> a9-?-;57. sttad�wl�voa w c ) <br /> CITY `^ IG�QSM STATE ZIP <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 /> 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,SPATE and FEDERAL laws. )_ <br /> PPLICANT'S SIGNATURE�.� l�(,��� DATE: 3-1 Lo <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL7CANT is not the BiwNG PARTY proof of authorization to sign is required Titre <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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availaat the same time it is <br /> provided to me or my representative. ~ M <br /> TYPE OF SERVICE REQUESTED: IVF <br /> COMMENTS: <br /> Inranalt a(14, i <br /> ACCEPTED BY: Cur - S GU EMPLOYEE#: DATE: .'L ( i7 -ZZ <br /> ASSIGNED TO: �� EMPLOYEE#: DATE: Z— <br /> Date Service Completed (if alr ady completed): SERVICE CODE: DO/ P1 E: 3 <br /> Fee Amount: y Amount Pai ISS Z20 I <br /> Payment Date /O 2Z <br /> Payment Type SG Invoice# Check# 89170S Receiv d By: <br /> Z20 1 <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 �p ������p Is <br />