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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />2 <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />BUSINESSNAME i <br />SERVICE REQUEST # <br />Di v�5 <br />( t2 <br />HOME or MAILING ADDRESS <br />5ooa6o9� <br />5611f5blu'd <br />ASSIGNED TO: <br />ASSIGNED <br />EMPLOYEE #: <br />OWNER/ OPERATOR ,.. <br />CHECK if BILLING ADDRESS <br />�',u �CIIVPi.S <br />I SERVICE CODE: 00 <br />PIE: <br />Fee Amount: <br />FACILITY NAME _ <br />I <br />SITE ADDRESS �� <br />-,()(�Q.1>.d�S ave- 5 <br />Payment Type <br />I <br />S'l/��iF46L''IL <br />e <br />ffe# <br />Street Numher <br />Inon '— r Street Name <br />City <br />Zip Cade <br />HOME Or MAiUNG ADDRESS (If Different from Site Address) <br />a vI <br />Ar; -1 o _ _ Sbl d Number <br />Strea <br />_ <br />CRY I <br />STATE L Zip <br />PHONE #1 <br />LAND USE APPLICATION # <br />(300 5049% <br />PHONE#2 fir. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REOUESTOR <br />REQUESTORf_�, p CHECK if BILLING ADDRESS❑ <br />�-1- > <br />F' <br />BUSINESSNAME i <br />PHONE#' <br />z 2 <br />Di v�5 <br />( t2 <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY STATE ZIP <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 applicati and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST T FEDERAL. laws. <br />APPLICANT'S SIGNATURE: y DATE: I� qty c�GO x <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER L:J OTHER AUTHORIZED AGENT 13 V1 Ce. -F& 0 CVf k'Arl' i <br />JfAPPLICANT is not the B&LINQPARTY 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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVnRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />nrnvided in me or my representative. <br />r-- ---- _ - - <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: ) <br />SE'CtwQd—) ��%tt(( 5�'ltl(c(.�.a� ;ter{ �C-E.. �ti v -o J - w -4-1s rI°t' pa6qedl <br />(N .Q. �D V� a i' .:�L`�,Vl2 l •e.. l�iZ YY'1C(. Ct l2 G, t -kr"a+ii ?ts --�D fir, SYyl:�r_L <br />S G-!— I.rJ � f` �.G�•b�;oC?c�� �1�C1�'ut-2.S �ESU� V <br />ACCEPTED BY: (� <br />C, <br />EMPLOYEE#: O L <br />DATE: <br />( q, 2 2— <br />ASSIGNED TO: <br />ASSIGNED <br />EMPLOYEE #: <br />DATE: <br />/ 7,4 ,Z <br />Date Service Comple d (if already comp d): <br />I SERVICE CODE: 00 <br />PIE: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />e <br />ffe# <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11117/2003 5 <br />