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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# =Szftfiq� <br /> VICE REQUEST# <br /> -r U0�5og <br /> OWNER/OPERATOR <br /> / Frnk\u �I , CHECK if BILLING ADDRESS <br /> FACILITY NAME a^Co qZ ( r RO ` T0. 0i tia� <br /> SITE ADDRESS Sot ✓!+'.k1_ A <br /> Street Number Direction Gl l dlt ZI o Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 3 R S +. Street Number Street Name <br /> CITY STATE zip <br /> R.'Iverbanlc Ca 9536 <br /> PHONE#1 Ezr. APN# LAND USE APPLICATION# <br /> ( 2011) X65 - 37Q6 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> (2011) qig - Sog <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK If BIL <br /> p <br /> I \ / bVl VI 11 LING ADDRESS <br /> BUSINESS NAME Y Exr• <br /> aWS Ek G ao PHONE as -716G-3-746 <br /> HOME or MAILING ADDRESS FAx# <br /> Sas L ( ) <br /> CITY •\v rbAnk STATE (a ZIP q 6 <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ��tt DATE: 0 6/91 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER bf OTHER AUTHORIZED AGENT❑ <br /> I7APPLICANT is not the BILLING PARTY 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 t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an e time it is <br /> provided to me or my representative. R <br /> TYPE OF SERVICE REQUESTED: JA <br /> c O <br /> COMMENTS: p <br /> Sc RavMF �ry <br /> 4� t <br /> G • e� <br /> ACCEPTED BY: S EMPLOYEE#: V30 DATE: / „ ?' <br /> ASSIGNED TO: EMPLOYEE#: DATE: I , <br /> 1124?- <br /> Date Service Completed (if already Completed): SERVICE CODE: O P I E: I n�3 <br /> Fee Amount: vu Amount Paid I�� Payment Date 2 -V <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 n�� e( _ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />