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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FA0000025 SR008(oa38 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> - '&i ? <br /> FACILITY NAME f <br /> 0 LI 'S Clorner- - �1 <br /> SITE ADDRESS P54- 11 E• Lone Tree RGI. ESca lon <br /> O� Stree!Number Dlrectian Street Name Lit <br /> Zip Code <br /> HOME or MAIL,IING, ADDRESS (If Different from Site Address) <br /> 500 /`r la`s / / ' <br /> U Street Number Street Name <br /> CITY STATE ZIP <br /> v ) 4 5 35Z-/ <br /> PHONE#f ExT• APN# LAND USE APPLICATION# <br /> (?ar( ) '37, —q a—+ <br /> PHONE#2 ExT' BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REDUESTOR <br /> BILLING ADDRESS <br /> - ✓iU M �rn� Z CHECK if <br /> BUSINESS NAME PHONE# Ex. <br /> Rossetti ' rner ( ?".n '7?/ <br /> HOME or MAILING ADDRESS FAX# <br /> Soo k Q ( ) <br /> CITY ST E ZIP 53 C <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 work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FED' L laws. <br /> APPLICANT'S SIGN AT — DATE: <br /> PROPERTY/BUSINESS OWNER❑ O ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> Lf APPLICANT is not the BILGING PARTY proof of authorization 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Sagte time it is <br /> provided to me or my representative. 10!P. <br /> TYPE OF SERVICE REQUESTED: ��/ T <br /> COMMENTS: <br /> SNI � 2f� <br /> ✓oq <br /> Flynt QUtN C <br /> NE9LT 00(Q 0 N <br /> ACCEPTED BY: -SC a r C u L S C O EMPLOYEE#: DATE: fl - <br /> a <br /> 3 <br /> ASSIGNED TO: _ Fa h m EMPLOYEE#: DATE: 11, ' / , oODIC .27 <br /> Date Service Completed (if already ompleted): SEO <br /> RVICE CODE: / I IP/E: boQ <br /> Fee Amount: 1 5 Amount Paid /5�,OL? Payment Date /( <br /> Payment Type Invoice# Check# J 'i L.1 / J Receiv d By: <br /> EHD 4 �� I I 21 SR FORM(Golden Rod) <br /> REVISED EO 11/1 11/17/2003 J <br />