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SAN JOAQLIIN COUNTY ENVIRONNIENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�'eS]r5e �0,�- <br />(� <br />FACILITY ID # <br />COMMENTS: <br />M,e C'—C'ur� <br />^ SERVICE REQUEST # <br />(�o0 0 a9- <br />OWNER -f OPJERATOR <br />��1 [CCJJJ l�C <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />y <br />Street Number <br />Dlrecticm <br />Street Name <br />94Al A <br />cityZI <br />41,1 <br />Code <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />ASSIGNED TO: <br />Street Name <br />CITY <br />` <br />nl <br />STATE ZIP <br />PHONE #1 <br />1 ( <br />E),. <br />APN #0i��l n� <br />[✓� /l/I v <br />LAND USE APPLICATION # <br />ON #2 <br />C' ► �� ago � <br />Ext <br />BOS DISTRICT -7LOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR PAY <br />REQUESTOR (^_ <br />CHECK If BILLING 91DR <br />BUSINESS NAME PHONE# 2E 20 <br />( 1 <br />HOME Or MAILING ADDRESS FAX # I IiN R'R "V OU1y <br />CITY STATE ZIP R EA/r <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site andJor 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, f TE n [ :RAL laws. <br />APPLICANT'S SIGNATURE: `/G DATE: <br />PROPERTY / BusriESS ONVNERj1Q OPERATOR AlANAGER ❑ OTIIER AUTIIORIZED AGENT ❑ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environ nentaUsite assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HE.At.TII DtiPARTMENT 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: L <br />(� <br />COMMENTS: <br />M,e C'—C'ur� <br />1 <br />i Lk-' c c <br />( n <br />1 AJ le <br />1�J Q��SCl./�1 <br />— <br />r� osa—SZ- r ---2L ora -�an n -C <br />vyi--) <br />�P4 <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />` <br />nl <br />DATE: 7 <br />Date Service Completed (if already completed): <br />\til i ' t� I ZZ <br />SERVICE CODE: D <br />P ! E: �o "7 <br />Fee Amount: 3 ] <br />Amount Pai �z bU <br />Payment Date <br />Payment Type ! J <br />Invoice # <br />Check #/0 <br />Receive By- <br />EHD 48-02-025 C 6Lr" �4 ► ` ` I�u SORM (Gol <br />REVISED 1 111 71200 3I ! G <br />24 C. to o.����C� I � J I �Ct <br />Ci <br />