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7�. <br />87A <br />.AW <br />f-9 <br />mm <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />Gt' <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />HOME or MAILING ADDRESS <br />V�o ' �8• 16 � <br />SITE ADDGR}ESS <br />IS� ` ( eet Number <br />Direction <br />H � D <br />Street Name <br />1 0L �o?�` <br />L Cit <br />'�jZi CCode <br />HOME or MAILING AD RESS (If Different from Site Add sl <br />Sheet Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE # i EXT. <br />APN #U -3 T Lf —7 <br />LAND USE APPLICATION # <br />PHONE #2 ExT. <br />( ) <br />BOS DISTRICT /^ <br />NI <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REOUESTOR f <br />/very, <br />CHECK If BILLING ADDRESS <br />Gt' <br />-ty� / O-P� s iJJ(Wr- <br />BUSINESS NAME / <br />? <br />/k 1✓4 "Ov �p a fvr M rk+ m/y�' . 0 6 Z022 <br />PHONE # EXT, <br />3►Zo <br />HOME or MAILING ADDRESS <br />V�o ' �8• 16 � <br />FAX # <br />x <br />( ) <br />CITY <br />STATE /4 ZIP '95-2y <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site andlor project specific ENVIRONMENTAL HEAI.TH 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 ST E and EDERAL laws. <br />APPLICANT'S SIGNATURE: D.%,i t:: 7 — L6 LdZZ <br />PROPERTY/ BCSINESS OWNER❑ OPERATOR / MANAGER ❑ O -I ITER AtiTHORl7_F.D AGE,.'i .r•- &r� <br />If APPLIC-INT is not the BILIJN(G PARTY, proof of authorizaterm 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 to the SAN JOAQUIN 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 RE/QUESTED: L),(t 'Cn � C.:1eJ1+k '6Y �e11 GIN C�eN}� }Q W,'I+,eT, <br />COMMENTS: , (e f I t 1� "'-I] I S CJ. C t Yl C( d ty <br />�r�DyL)Y1C <br />a RA Ir <br />T <br />coAlimcr �- ro O�VSGt� �! � <br />CE�vE® <br />-ty� / O-P� s iJJ(Wr- <br />p�Y . ,rr�l� Sv/� �� �vRotily AUL <br />? <br />/k 1✓4 "Ov �p a fvr M rk+ m/y�' . 0 6 Z022 <br />P(e r7ln iG of h°u S' 1 <br />SAN OAQUIN COON <br />Ty <br />ACCEPTED BY: �'� L L— <br />EMPLOYEE #:QRT <br />ASSIGNED TO: F R <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: J <br />P / E: <br />Fee Amount: <br />Amount <br />Paid <br />Payment Date 2L <br />Payment Type ,I <br />invoice # <br />I <br />Received By: <br />LrU' "U v <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />