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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or PropertyFACILITY <br />BUSINESS NAME DDD'sTile, e�� iooi �Rj\ e ioq <br />ID # <br />HOME Or MAILING ADDRESS , ^ l Y✓, ��� <br />Ivry <br />SERVICE REQUEST # <br />Co m�r�cc�l Ms 9R <br />kily bwld i'11 G, <br />OWNER I OPERATOR <br />r r t �( <br />`\ <br />ry `T,( n �� JE CK If BIWNG ADORES5 <br />�n n ,^ rl t/1 CAU <br />+L�Cn 1� �/ r 1 V 11/ V CJ <br />FACaDY NyME�l// <br />fl S $ <br />J�AYRE <br />SITE ADDRESS <br />—1 <br />ollc <br />1 <br />QStrew <br />DATE: <br />M&C <br />L0 Street Number <br />n <br />Name <br />y <br />SERVICE CODE: JC2 3 <br />HOME or MA uNGG ADDRESS (If Different fr`o jm(S�ite Address) <br />I IV0 `nl CAO— ��P' �� <br />P116 j Vd Z <br />'A�� <br />E <br />1 \ <br />reel Number <br />Payment Date <br />ra m VIG,1�C <br />Cm � <br />Invoice # <br />STAT ZIP O c "IZL` pEPARTME <br />" 1 J "j <br />PHDNE#1 <br />En. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />En. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK t BILLINGADDRESS <br />G`CAnvo7 <br />BUSINESS NAME DDD'sTile, e�� iooi �Rj\ e ioq <br />PN74-7Z--7_VU5 <br />9 <br />HOME Or MAILING ADDRESS , ^ l Y✓, ��� <br />Ivry <br />FAR# <br />( ) <br />CITY C (D STATE (' ci LP <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 t the r to rformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE EDERAL a s. <br />APPLICANT'S SIGNATURE: DATE: 0/'� `Z J/ ZZ <br />PROPERTY / BUSINESS OWNER❑ OPE NAGER OTHER AUTHORIZED AGENT f t W) d 'r <br />1fAPPLIC4Nrisnotthe BILLINGPARTT proof of authorization to sign is require 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 environmentaVsite 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 REQUESTED:(Z, _ i ef t y, �� <br />I S J yt w(! M .M I VkJ 10 <br />00 1 <br />// <br />COMMENTS: 00 1 —W ,�t� e -S <br />rr5 <br />s <br />17v3i-AlI to MJC' <br />kily bwld i'11 G, <br />'Al5to fo-fl Il <br />1 I <br />T'T,1 <br />S2V' ---6C <br />° p m)q,� <br />I 10 Codes VG-XdLL3- <br />fl S $ <br />ACCEPTED BY: dv\—� <br />EMPLOYEE#: I <br />(� <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: 2 -y <br />Date Service Comp a (If already completed): <br />SERVICE CODE: JC2 3 <br />P116 j Vd Z <br />Fee Amount: Ob <br />Amount Pa <br />6 , 6)D <br />Payment Date <br />Lj <br />Payment Type Ok— <br />Invoice # <br />Check # ' I <br />eceiv By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />7- <br />D D <br />ry <br />