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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />�v�i <br />�LU+LX'CWl-� <br />FACILITY ID # <br />5+1 <br />c SERVICE REQUEST # <br />J <br />OWNER / OPERATOR <br />CITY STATE ZIP <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />DATE: 17-24-.7 <br />SITE ADDRESS •S <br />Street Number <br />Dlreetion <br />/� fto <br />l• atreotRNyemve u' �1 <br />CI <br />clnmto <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />fir\ <br />Fee Amount: 1,6_6 <br />STATE ZIP <br />104 `1 ((�� <br />`7 �LtNJ <br />PHONE #1 <br />(gq) qaa- us <br />ExT. <br />APN# <br />Invoice # <br />ND USE APPLICATION# <br />PHONE #2 <br />ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE, QUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />PHONE # EXT. <br />HOME Or MAILING ADDRESS <br />FAX # <br />CITY STATE ZIP <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 FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />/ly�., atmea DATE: k�� a,R��a Cra'd <br />PROPERTY/ BUsINEssOWNERL,.V� ' O'P—ERA—TOR/MAN ER ❑ OTHERAUTRORIZED AGENT 13 <br />11APPLLCANT iS not the 13LLLlNG PAR7T proof of itudtorl7fldon to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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:: <br />COMMENTS: T.Ke.O+f -Yo'cv--eN. <br />OW hl.t7 40 <br />O'bYLiySt <br />C+`�"C1-c— <br />ACCEPTED BY: r <br />EMPLOYEE #: "r'�2Q <br />DATE: 17-24-.7 <br />ASSIGNED TO: <br />EMPLOYEE #: O'T 1913DATE: <br />'l - 7 2 <br />Date Service Compl d (if already completed): <br />SERVICE CODE: <br />PIE: <br />Fee Amount: 1,6_6 <br />Amount Paid <br />5 �, <br />Payment Date r, 2 <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 <br />REVISED 11/17/2003 <br />SR Fi RM (Golden Rod) <br />S, <br />