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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Res o. 01 �1�aigg9(O <br /> OWNER/OPERATOR I� C <br /> 1 6M l}� J 4p_�OL trio CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> �ba <br /> SITE ADDRESS S L,vL kh gJc2�q <br /> 3 6 Street Number DlreoHon ams e L�.h CI ZiCode <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> c (�"S-~Z,L� h L,Q <br /> Imo' Street Numb¢r twt �Street Name <br /> CITY STATE ZIP <br /> L at K4-o P c.A L� 53 3b <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> ((O'0) 2-'l� -3 2 <br /> PHONE#2 Eu. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 1 <br /> /�I I`�'�t (��y-fir„ l CHECK If BILLING ADDRESS <br /> BUSINESS NAME b V JC 1 1 /�/V PHONE# EST' <br /> S)'Si 1 g J&)bcl &Sv 2-' 32� <br /> HOME or MAILING ADDRESS FAX# <br /> s I Po(s e , ( ) <br /> CITY STATE C ZIP p13330 <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, STATE d FEDERAL laws. <br /> APPLICANT'S SIGNATUrRt/E: DATE: D 2 '2 2 / 2 02� <br /> PROPERTY/BUSINESS OWNERL OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the B1LL/7VG 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and me time it Is <br /> provided to me or my representative. n <br /> TYPE OF SERVICE REQUESTED: -� K.LC � FO <br /> COMMENTS: cly <br /> ?62022 <br /> �E9C 10) <br /> C JJT <br /> ACCEPTED BY: EMPLOYEE#: /,2( DATE: '�Zy�2 Z <br /> ASSIGNEDTO: _ EMPLOYEE#: �c DATE: -Z7-2— ZZ <br /> Date Service Co pleted (if already completed): SERVICE CODE: P I <br /> Fee Amount: Z Amount Paid Payment Date 2 L <br /> Payment Type Invoice# Check# `(333 7 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />