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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business <br />6E6+ <br />or Property , _SYe____ <br />FACILITY ID # <br />r: A <br />SERVICE REQUEST # <br />q(10 (1 (0-2-419 <br />OWNER! OPEROOR <br />Ykdri CHECK If BILLING ADDRESS k li t) i 1 I, <br />FAciury NATE i r 1 II(t i i )1 a+ c3c Irv' V eS <br />SITE ADDRESS <br />I C H I Street Number Direction <br />, <br />• 171. 11.. V L zreCiAki( ' 4" I ) . V1/4--ht I C I liT- -3-1(C CL i ) <br />7— <br />( ZtC1-46.1-id <br />HOME or MAILING ADDRESS (If Different from Site A9iclress) <br /> <br />,7 ____, <br />L-11 i i 6 i IC' k /a • ( j( ti l- t <br />1 <br />k '4141 ber Street Name <br />CITY <br />( Vir <br />, STATE / <br />I <br />ZIPO ---) i Ci <br /> <br />i ---/ C 4. 1 <br />PHONE #1 EXT. <br />QLC1 '7 1 ' ) D.1 <br />APN # LAND USE APPLICATION # <br />PHONE I/A <br />ni 0 i <br />EXT. <br />1 --). qtz. r,..-- <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS rail <br />BUSINESS NAME 1 ( , A c (‘))ã <br />1 <br />ti- „St) Lid i ( es c <br />,4_. <br />P(7"ci 7)3L-f ,)0- HOME or/ Mr° rIrREIS)) L Ir. v._ipi , c i ocit _e.,,..., ( t jaci j <br />, --,splE <br />Flt,(..,. , 3 <br />,( CI 3 Li-ig.- I Li (S/ <br />ZIP ( 7‘j.5" t q <br />CITY e.--11Ccl. Viii i -1 i <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 FEISERAL laws. r a <br />APPLICANT'S SIGNATURE: DATE: / <br />—• <br />PROPERTY / BUSINESS OWNER':/ OPERATOR / MANAGER LI OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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. <br />TYPE OF SERVICE REQUESTED: 81 <br />44)0 COMMENTS: ii'c <br />-4441 /2 , (023 <br />EM.4Q(J/N ki,j, <br />t2k.7\4?.:N tiii.V7}' <br />ACCEPTED BY: EMPLOYEE #: DATE: . 'tN 7714E:iv r <br />t <br />ASSIGNED TO: EMPLOYEE #: DATE: <br />Date Service Completed (if alreAdy completed): SERVICE CODE: <br />(4' <br />PIE: ( Op* <br />Fee Amount: 1 5 Amount Paid/5-6,, OD Payment Date / 20 <br />Payment Type Invoice # Check # Received v: SIN . i <br />Title <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003