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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# AERVICE REQUEST# <br /> lvwl-r GOO,> PjesT"alkll F'� d 000X13 8 ftxtr-*��3 <br /> OWNER 1 OPERATOtav&eCHECK If BILLING ADDRESS <br /> FACILITY NAME qw �C-tC . C� <br /> SITE ADDRESS I, r. 1��,� AteO C r�Zc <br /> Street Number Direction Street Name CI ZiP Code <br /> HOME Or MAILING ADDRESS (if Different from <br /> Site Address) <br /> Jrek —t Street Number h-- t`re t Name <br /> CITYu� ,� f f�^ STATEI` <br /> �- <br /> u'l�F— V ,JP. N • C 6r-- <br /> N APN# LAND USE APPLICATION# <br /> PHONE2 � . &(e � T• BOS DISTRICT LOCATION CODE <br /> IV ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r - <br /> v!0 CHECK if BILLING ADDRESS <br /> G <br /> BUSINESS NAME q—^• t C __ „D `N/ % t� <br /> HOME or MAILING ADDRES v ay t (�(S� l'• ` F # t <br /> $3 l �� c�xw� v�lz 1& 911 v 33. <br /> CITY !� I t A�� ATE ZIP 1 <br /> BILLING ACKNOWLEDGEMENT: Lithe 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,ST - n G�] <br /> APPLICANT'S SIGNATURE: DATE: 4• <br /> PROPERTY/BUSINFSS O\YNER OPERATOR/NLANA OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization 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 time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: �V <br /> COMMENTS: <br /> �4 <br /> y��Ro�/H 201,9 <br /> Ty0 pgFHS4 <br /> RTMR�T <br /> ACCEPTED BY: EMPLOYEE#: Zl 3 DATE: 14 Iz4C C <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Complete (if already completed): SERVICE CODE: P/E: I �, <br /> Fee Amount: Amount Paid 1502 • _ Payment Date 4 <br /> Payment Type �,,, ( Invoic/e�# ,f Check# Received By: <br /> EHD 48-02-025 l.�{1 J'lf � �b r �`t 72� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> QIP 2L ELP <br />