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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> U� 5f CI / <br /> o a Sf yDd u�5 CHECK if BILLING ADDRESS <br /> FACILITY NAME rco 5-469 11 y, <br /> SITE ADDRESS 5 w i l S o n W CLy S-(v c-k-fbvi Cj s-z p ej <br /> 130 Street Number Direction Street Name C ity Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> eo6cx 6Q3 v Street Number Street Name <br /> CITY - STATE ZIP <br /> 4-,^4e-,S IGT KICLI 90702--0 5.3 <br /> PHONE#1 E.T. APN# LAND USE APPLICATION# <br /> (20q) 466 - <br /> PHONE#2 EXT. BOS DISTRICT —7LOCATION CODE <br /> S7 62-3-3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - n <br /> /A 601-TEZ CHECK If BILLING ADDRESS <br /> BUSINESS NAME CC// c� PHONE# ExT, <br /> 646IX ES F. �0,� 5 60, 2-/3 2lb-55-39 <br /> HOME or MAILING ADDRESS FAX# <br /> /3 701 S o v rH <br /> CITY /� �2�� f� STATE / ZIP -70149 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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,Standard TE and ED RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER �OPERATORMZWAGER ❑ OTHER AUTHORIZED AGENT Er" PE,N!I TE�ht <br /> If APPLICANT is not the BILLING 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 available and at the same time it is <br /> provided to me or my representative. PAYMENT <br /> TYPE OF SERVICE REQUESTED: (( .ST- AE—r-?P-,6F—r--t— `O <br /> COMMENTS: DEC 13 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: C EMPLOYEE#: r—, DATE: t 2-11 <br /> '�/0 <br /> ASSIGNED TO: D EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: /vav� P I E: .�3 <br /> Fee Amount: 7� &0 Amount Paid Payment Date I y/(3 <br /> Payment Type ✓" Invoice# Check# 23 Received By: 4t <br /> U <br /> EHD 48-02-025 SR FORM(Golden Rod <br /> REVISED 11/17/2003 <br />