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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FA(CCIIfLIIT/^Y IDG#� cam,/SERVICE R-EEQQUUE,SrTc#� <br /> 'K.�1cAt1 Ci Cr1VC.vt��NC� JTt/Y'{. �11 vVV ✓ 1 � .J(Lc5b 1 N_J ) <br /> OWNER/OPERATOR <br /> G��rI�, I vkG , CHECK ItBILLING ADDRESSO <br /> FACILITY NAME Gh6VrrM S}ash IT- <br /> SITE ,,y <br /> ADDRESS 01 q 91"(1V/, t- 1.-C/1 r) t; G(Ci (Jyl 95116 <br /> street Num ber I Direction Street Name Cit Zip Code <br /> HOME or MAILING <br /> �ADDRESS (If Different from9Site Address] <br /> U r-3i r Z ,TTT ' L t h S�treet Number Street Name <br /> CITY 1^{ic� STATE C^ ZIP 9�2--L <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> 0P-b Gni —��� y © ab�v -f) <br /> PHONE#2 Exr. BIDS DISTRICT LOCATION CODE <br /> ( ) OO <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR / /.�• <br /> A.1tIV1y lvVN Vavrt - • CHECK If BILLING ADDRESS"• <br /> BUSINESS NAME GhcJ�.rw. S'�t.�� .byY3 PH�t!€# - ` -;3 4'' <br /> HOME or MAILING ADDRESS A�Y1: Lt'U'V%J-G FAx# <br /> CITY T; f -ee, 1 STATE C,+- ZIP y L <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 d FEDERAL laws. J <br /> APPLICANT'S SIGNATURE: DATE: 7 3 Yl/r _ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENT❑ eyvkf)dAAd CGa�/Z� <br /> If APPLICANT is not the B1LLlNG PARTY proof Of authorization t0 sign is required Titfe <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 availabld at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: yF <br /> COMMENTS: <br /> 3 / <br /> HHB NT�O,ry <br /> TMFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: -Z X <br /> ASSIGNED TO: EMPLOYEE#: DATE: '5 <br /> Date Service Completed (if already completed): SERVICE CODE: C ) P I E: I 1�0()a <br /> Fee Amount: C)0 Amount Pai � ,�� Payment Date <br /> Payment Type JCK Invoice# Check#�G77r RecelvedBy: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 S <br />