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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �0002(l02- 12003 �� <br /> OWNER/OPERATOR nj2 <br /> CHECK If BILLING AODRESSO <br /> FACILITY NAME �7,,^�Icr-\�an ^ 5 „•� -Rfe- <br /> SITETE ADDRESS_l"'r•I/�J m �/��Y��l Y11 �/ ��� �SZU <br /> Street Number Dlrectlon Street Nama C 21 Code <br /> HOME <br /> or MAILING ARES. fferenttfrom Sne Address) <br /> tD� v0 DDVA d- <br /> W Street Numbar Street Name <br /> CITY �L F I U vl STAT(t� ZIPq j Z ol <br /> rl U <br /> PHONE#I Ea'• APN# LAND USE APPLICATION# <br /> 0,uq ) 7UZ - 2Lpg� <br /> PHONE#2 Ems• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 1n O 1/1 CHECK if BILLING ADDRESS <br /> BUSINESS NAME Y� 1 r I 'V^ nV r• i 1 1� P NE �(0 2- <br /> -U r nl <br /> HOME or MAILING ADDRESS V`^` J Vt l FAX# G a <br /> u1 3o NA R1#-OA�s& W ( ) <br /> CITY -tl/ K.hG1n STATE cler ZIP GT-S ZU <br /> BflAJNG 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 FEDERAL laws. <br /> l - 2 <br /> APPLICANT'S SIGNATURE: b4/ V.``` - — DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13 <br /> IfAPPLICANTis not the BiLLGVGPARTY proof ofauthorizadon 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 en tat/sue assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avail a�f to time it IS <br /> provided to me or my representative. Vr IQ <br /> TYPE OF SERVICE REQUESTED: W 1`S I.1_ i tA, im ,rA <br /> COMMENTS: JpgOil <br /> FlFIN COUN <br /> q �P <br /> ACCEPTED BY:0 A LVln n -e 11 EMPLOYEE#: '7&t� DATE: p„ 27 3 <br /> ASSIGNED TO: WJt tg5J Q a,[,eK EMPLOYEE M Ot g I X DATE: J V !i <br /> Date Service Co pleted (if already completed): SERVICE CODE:DO <br /> PIE: I Q D Z <br /> Fee Amount.'NO Amount Paid Payment Date l 2.3 <br /> Payment Type akeInvoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />