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SAN JOAQUIN C9UNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />BUSINESS NAMES / <br />( <br />FACIL�I/TY ID # ` <br />HOME or MAILING ADDRESS <br />REQUEST # <br />�D L.t L.I�-l• �ll1G <br />'� ( <br />/SERVICE <br />�l `':moi"/ <br />COMMENTS: <br />OWNEg / OPERATOR <br />' <br />j � -e(� / Co <br />I o*l C�-."/"roa o X- C.J.C��w-,pcs <br />CHECK if <br />BILLINGADDRESSE] <br />iiL•L-L[.S'j"— <br />W� (��\L�. (/riVll�✓ <br />S l(/Y•lLt r"`rt fr�, <br />( J '-'L �%�'�-t r -`/lam <br />FACILITY NAME <br />._ <br />y <br />DATE: <br />SITE ADDRESS <br />�r�HU GC <br />/1C/ic-tel <br />./Zip <br />Street Number Direction <br />Street Name <br />SERVICE CODE: S•2-� <br />Code <br />E: 1f*0y, <br />Fee Amount: 1 E . t 1J <br />Payment Date <br />( l (d)a <br />HOME Or MAILI.t{�71G� ADDRESS (If Different from Site Address) <br />Payment Type <br />Invoice # <br />Street Number <br />Street Name <br />Received <br />By: <br />CITY n n <br />STATE <br />n ZIP9 <br />C <br />f <br />PHONE#1 ; EXT, <br />APN # <br />LAND <br />USE APPLICATION # <br />(z�y) <br />PHONE#2p y _ �I T• <br />1, Z- <br />CO I <br />BOS <br />DISTRICT <br />LOCATION CODE <br />t ) <br />CONTRACTOR /SERVICE REQUESTOR <br />REQUESTOR <br />U C L4 CHECK if BILLING ADDRESS <br />BILLING <br />BUSINESS NAMES / <br />( <br />PHONE# ��2 _��,� ri• <br />6 <br />HOME or MAILING ADDRESS <br />FAX # <br />CITY NVSTATE ZIP <br />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 projector <br />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" performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, Sand FEDER v laws PAYMENT <br />APPLICANT'S SIGNATURE: rrr��� DATE: y p RECEIVED <br />PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHERAUTrimuZEDAGENT ❑ IANI 11 <br />If APPLICANT is not the BIcc7NGPARTr proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the prop&1JRMl�Ir��9,L TY <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environtnentl ASI�AtppdENT <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: Sphel (,Jc.S'f'e-- Pr -J m„— lam. Cl.�� <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />lcc <br />COMMENTS: <br />j � -e(� / Co <br />I o*l C�-."/"roa o X- C.J.C��w-,pcs <br />�-• �1 <br />��—/ <br />iiL•L-L[.S'j"— <br />W� (��\L�. (/riVll�✓ <br />S l(/Y•lLt r"`rt fr�, <br />( J '-'L �%�'�-t r -`/lam <br />/ _ <br />l LL IC 7 Lti ��(^ <br />ACCEPTED BY: L t V 66.I j8'A <br />EMPLOYEE #: .Z <br />DATE: <br />ASSIGNED TO: 6 A -C r SCS <br />EMPLOYEEM 4�0 L3 (A <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: S•2-� <br />P <br />E: 1f*0y, <br />Fee Amount: 1 E . t 1J <br />Payment Date <br />( l (d)a <br />Payment Type <br />Invoice # <br />Check # 43q,41+ <br />Received <br />By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />