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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ca-F e v SIR <br /> WNER/OPERATOR `" � tNv <br /> , 1 f CHECK If BILLING ADDRESS <br /> FACILITY NAME ( V1 1 (1 I t /a l I/. L I n n/� / <br /> SITE c V L��IA� I� V�rrb � LV GL\ �Sa`�b <br /> L-1 J <br /> Street Number Diretaon Street Name city zip Caft <br /> HOMEIjr MAILING ADDRESS (if Different from Site Address) <br /> ox I o Street Number Street Na <br /> CITY STATE �-.,-• ZIP <br /> PHONE#1 EM• APN# LAND USE APPLICATION# J <br /> ,W ,,) CpD - qb q q <br /> PHONE W Fx . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAMEExr_ <br /> DO� ceZZa.� P : l�o3- (P�` <br /> HOME Or MAILING ADDRESS Po g�X 13g (Atte ) <br /> CITY n r 0 STATECA ZIP qS '1-3 <br /> iWILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> I cknowledge 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,S�' TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: l�V {�VVW DATE: Oy 17b Z,2 <br /> PROPERTY/BUSINESS OWNERLYI, OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLDVG PARTY.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 same time it is <br /> provided to me or my representative. rw <br /> TYPE OF SERVICE REQUESTED: ✓V r lAT+��, <br /> COMMENTS: AVG 15 <br /> SAN IWI'4QU RO A+DO20 <br /> MST y DTE M NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: �/ 2 <br /> ASSIGNED TO: D A <br /> EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /`t PIE: I ��2 <br /> Fee Amount: l Amount Paid Payment Date 8 1 Ica 1,22 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 V f OS 35M 1 <br />