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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o -V S 5 OWNER/OPERATOR S* / <br /> .at ,C, ` ," B7 LLC CHECK If BILLING AO0RES5 <br /> FACILITY NAME � <br /> SITE ADDRESS / <br /> Street Nv <br /> umber Direction J ''r� iµS�r �Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) t I I t!vt InVt A+r•-/h.i e fl <br /> Street Number N IN Street N`a'meW�-C/ <br /> CITY j>...^1At /'1 STATE A ZIP �7 � <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> ( >I) ( 9* — 4Z� <br /> PHONE#2 EXr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> I <br /> BUSINESS NAME PHONE#201 _S <br /> EXT: <br /> r wtlUs i C,- <br /> HOME or MAILING ADDRESS ' <br /> 11' •_` ,- , FAX# <br /> ��( ' r�l' ( ) <br /> CITY j,�Vir STATE / /N ZIP <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 FE ERAL laws. <br /> APPLICANT'S SIGNATURE: �c�o �!i'� DATE: 2 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> IfAPPL/CANT is not the BILLING PARTY proof of authorization to sign is required Ti Ne <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/sitle�a�ssessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the a (iy)te it is <br /> provided to me or my representative. ID <br /> TYPE OF SERVICE REQUESTED: �V <br /> COMMENTS: 0 <br /> �V��QU/N6 2QZ� <br /> N�l��U CU�.nt� E'9C77.t p PM���Nry <br /> M- 00 Ayn t n5 n CHv /� 1 "T <br /> ACCEPTED BY: EMPLOYEE#: 17 L) DATE: z� <br /> ASSIGNED TO: t EMPLOYEE#: 101 DATE: �1 Z <br /> Date Service Comp et (If already completed): SERVICE CODE: D P I E: 61 <br /> Fee Amount: 15 ,OD Amount Paldpe Payment Date ' <br /> Payment Type Invoice# Check# ` z�q ec 'ived By: <br /> EHD 49-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> Ply o l�00 <br />