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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> - I SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OG r iI?LFrye / L)IC6o q6 0�2e <br /> OWNER/OPERATOR p /�L. <br /> S /Y/Se� CHECK If BIL ING ADDRE <br /> FADIuiY NAME ( <br /> SIT ADDRESS / ^ QAC(//•• /+ 3'7 <br /> S Street Number Do-.m n C /( g„ea e //Ci G ZI. d. <br /> HOME MAILING ADDRESS (If IHerent from Si Add <br /> ' Street Number / ��Lt Na ���� <br /> CITY G G STATE ZIP <br /> PHONE#1 �T• APN# LAND USE APPLICATION# <br /> vol) 1 o Z <br /> (�7D� BOS DISTRICT LOCATION CODE <br /> CC --CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Z� Nn ,4/W �� ,1,( <br /> �/ �/L �� /�� tpECKIf BILLING ADDRESS 13 <br /> BUSINESS NAME !� `L �. PHONE# Z En. <br /> ( 7011) <br /> HOME or MAILING ADES ��/ ��, FAX# J U <br /> N. 43 <br /> ( ) <br /> CITY O STATE ZIP <br /> 'r7GG <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized ag ent 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 applicatiO 1e work to be erf ed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT FEDERA "w <br /> APPLICANT'S SIGNATURE: DAT <br /> PROPERTY/BUSINESSOWNER❑ OPE TOR/MANAGE OTHER ORIZED AGE \( <br /> 1f APPLICANT is not the Bl L!N ARTY,proof ofauthorhatia o 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 t0 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. P <br /> TYPE OF SERVICE REQUESTED: Mit CF� T <br /> COMMENTS: -ryR U <br /> 7 2p�6 <br /> . SA N'l0AQUI <br /> h���UO PAHTOU� <br /> APPROVED BY: EMPLOYEE#: 000 DATE: <br /> ASSIGNED TO: 490 EMPLOYEE#: 0 s3 DATE: •� <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: <br /> Fee Amount:$ tr Amount Paid d�g, b Payment Date 3 Ub <br /> Payment Type ✓ Invoice# Check# 106 Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 8-5-02 <br />