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SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ` <br /> 0S 6-7 U �� � �marc CHECK If BILLING AOORE35❑ <br /> FACILITY NAME <br /> �grrll'L�Q flC7viPr� <br /> SITE ADDRESS 26 Z� E aTh 5T 6-5 To tr Ton 95Zo5 <br /> Street Number Olrectlon Street Name city ZJP Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 2 6 F: $ T h 5 T Street Number 7 h <br /> Street Name <br /> Crtr s7-0 irIrr V C PrSTATESTATE ZIP <br /> PNONE#i EST• APN# rLAND USE APPLICATION# -1 <br /> (tog ) y05IB514 <br /> PHONE#2 EaT• BOS DISTRICT LOCATION CODE <br /> ( 26 ) SqB90`1ti 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAMEPHONE# E.. <br /> 3 <br /> Fa rn I-.Ia y7y rlu� JtL ) <br /> HOME Or MAILING ADDRESS n / Z i ! FAX# <br /> Lb > ( ) <br /> CITYI0C 6— <br /> .l�—•T- STATE �� ZIP 'rt5 20S <br /> BELLING ACIa1OWILEDGEMENT: 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 JoAQum <br /> COUNTY Ordinance Codes,Standards,STATE laws. <br /> APPLICANT'S SIGNATUR �� DATE: 3 I U- Z3 <br /> fuJ1( i <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPaLICANT is not the B1LLlNG 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 av3ijaji(p•arida same time it is <br /> provided to me or my representative. t'/�T Mir— <br /> RECENED <br /> TYPE OF SERVICE REQUESTED: O�p <br /> COMMENTS: � � ^ MAIC <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HFALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M �� DATE: '2 /1) 'LZ 4tJ <br /> ASSIGNED TO: EMPLOYEE M DATE: , I Fa o 3 <br /> Date Service Completed (if already completed): SERVICE CODE: 6 , P/E• 63 <br /> 1J <br /> Fee Amount: I T Amount Paid S� Payment Date <br /> Payment Type `7 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br /> X10 <br />