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I <br /> SAN JOAQUIN COUNTY E N IRONNTENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Fk Du 21S21 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L ►�n, '1"Uni - A ot�lyg 5Z Ste- DagScpg0t <br /> OWNER/OPERATOR IJ � J/� J/ f N^ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> Ldcl a�(etl l 41 <br /> SITE ADDRESS 610 ef�1Stree e / ��i � V <br /> Street Number pi action Street Name (�7 Ci <br /> HOME or MAILING ADDRESS 1If Different from Site Address) 1�D ECE'1, <br /> Street Number S reet Name V�D <br /> CITY STATE ZIP UG 15 201 <br /> PHONE 91 I EXT APN# /� LAND USE APPLICATION# oA(�(II <br /> 1 5(Dl 355 70 OLf 7— 1 �b` 370 HEALTH p NhAN7ENTqN r <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( � pl 36'S ��I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> SC�+rtVYr� C� 1 �ObCLs� CHECK if BILLING ADDRESSEY <br /> BUSINESS NAME ✓ - r PHONE# EXT• <br /> �x,� (� end j eU3tic, N�- r/ 7S$�- <br /> HOME or MAILING ADDRESS FAX# <br /> - cl L- ( ) -- <br /> CITY STATE -2 1 ZIP <br /> BILLING ACKNOWLiDGENTENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site hnd/or project specific ENVIRONMIENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed t me or my business as identified on this form. <br /> I also certify that I have prepared this ap lication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Code,St ar s,STATE a E ws. <br /> APPLICANT'S SIGNATURE: 1QiU DATE: <br /> g�5 /-,7 oZ2 <br /> PROPERTY/BUSINESS OWNEIR OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TORELEASEINFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, heret y authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOQQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED C�k3} ►S .Z YI (QG t/f I yl i C�CX 7JIJ Iti� '�' <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED To: A7 EMPLOYEE#: DATE: <br /> Date Service Completed pf already Completed): SERVICE CODE: P i E:ILI Dal <br /> 6 <br /> Fee Amount: I S Amount Paw IS- OT Payment Date <br /> Payment Typ6 Invoice# Check# � Recei ed By: <br /> I <br /> EHD 48-02-025SR FORM(Golden Rod) <br /> REVISED 11/17/1003 <br /> I <br /> I � <br />