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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />RVICE qUEST # <br />HOME Or MAILING ADDRESS <br />��V <br />FAX # <br />( ) <br />so 0� <br />OWNER/ OPERATOR `^tom-� CHECK If BILLING ADDRESS <br />FACILITY NAME <br />V \C—A/ <br />SITE ADDRESS <br />(� <br />v e > . '�2_D�/ <br />{ IAV tom., <br />Street Number <br />Direction <br />Street Name <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />ASSIGNED TO: � <br />EMPLOYEE #: <br />or�- <br />v v <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />ics� <br />PHONE #1 Exr. <br />( Ud �y- -2 <br />�APN # <br />g-`t�3t7- b(z) bTD <br />LAND USE APPLICATION # <br />-PA boo 3Z - <br />PHONE # �y ExT• <br />� <br />_ <br />BOS DISTRICT .`j'�J' <br />11 <br />LOCATION CODE <br />(11-S �' _C - V t l <br />` <br />Z i <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR^ �+_Q ��� �� 1 <br />l!� ` CHECK If BILLING ADDRESS O <br />BUSINESS NAME ,^ �{ IJ���t�lr�SZ t <br />PHONEji� _ �2 <br />b <br />HOME Or MAILING ADDRESS <br />��V <br />FAX # <br />( ) <br />CITY STATE ZIP �_ T <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: DATE: <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br />if APPLICANT is not the BILLIA'G PARTE, 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 to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the samA <br />it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: ���� �p�� �}/'� L vAt' FAv f• <br />COMMENTS: q// ICO <br />1 V <br />EHD 48-02-025 t�t (A&q`�R�-V I SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />�c� <br />Sq/v, G 19 <br />Q <br />� /y "W1 Q <br />F <br />4TyMRNC <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: � <br />EMPLOYEE #: <br />DATE: 2- <br />Date Service Completed (if already completed): <br />SERVICE CODE: 6- <br />PIE: <br />VV <br />Fee Amount: 1 Amount Paid.3��� <br />Payment Date <br />g <br />Payment Type V� 5� Invoice # Check # <br />sg r <br />Rece ved By: <br />EHD 48-02-025 t�t (A&q`�R�-V I SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />