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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY IU# SERVICE REQUEST# <br /> M Ear, Pe-f-f ' \ SKam3. -a <br /> OWNER OPERATORt CHECK if BILLING ADDRESS❑ <br /> min <br /> FACILITY NAME <br /> SITE ADDRESS ;7 <br /> MMT�� ��3(p <br /> Sheet N Lobar Dlreetlon Street Nema 1 ', CW <br /> HOME Or MAILINGADDRESS (If Different from Site Address) }/-.�5 <br /> 3 Street Number SIretN.. OJ _-(O <br /> CITY STATE ZIP <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> ( oq) '3k?- ToZ1 <br /> PHONE#2 BOS DISTRICT LOCATION LODE <br /> 12Uq i �o Z- <br /> CONTRACTOR/ SERVICF EQUESTOR <br /> REQUESTOR nI� ^/� ^ A <br /> CNECKHBIWNOADDRESS <br /> BUSINESS NAME /� (,��/�� / PHONE# En' <br /> HOME or MAKING ADDRESS FAx# <br /> --7-06K (AL ( ) <br /> CITY (Al3�,S STATE ZIP /1f IC-14 <br /> BILLING ACKNOWLEDGEMENT: 1, 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,STA and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: / ( DATE: /� 2 z- <br /> PROPERTY I BUsINESs OWNER51 OPERATOR/MANAGER OTHER ADTRomZED AGENT C3 <br /> IfAPPLlCANT is not the BIjlwl;A RTY.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 environments lfd ssment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at py� WY� <br /> provided to me or my representative. C C r Y <br /> TYPE OF SERVICE REDuesTED: CJAS tJI �LI/t �Pfs .� <br /> COMMENTS: SAN Jo422 <br /> liFgqQU <br /> LT�� Aco <br /> MAN <br /> ACCEPTED BY: ( EMPLOYEE#: DATE: S' 2 Z <br /> ASSIGNED TO: EMPLOYEE#: (3 $ DATE: ✓ <br /> Date Service Completed (M already completed): SERVICECODE: l 'P//E: v <br /> Fee Amount: 15-2- <br /> Amount Pai � �(�b Payment Date 527-22— <br /> Payment Type La--- Invoice# Check# eceiv By: <br /> EHD 4ti-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> 14'tz-s 30� <br /> 0S11'I1 S Z <br />