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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fA <br /> 000'LUg0 5(� 00�2�� <br /> OWNER/OPERATOR man / P d s <br /> CHECK If BILLING AOORE55� <br /> FACILITY NAME W iT `A Y W4& <br /> / V 1 � V YZ <br /> u ' VQpgvt:(�tles1 G�/ ,60 (l 5Z <br /> A S$ITE ADDRESS <br /> Cit ZI Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> S l ( r✓ CIQS <br /> PHONE#1 ECT. APN# LAND USE APPLICATION# <br /> (20) 3?3 - 7Do� <br /> PHONE#2 EXT. BO$DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ^ � n <br /> Sr t CHECK If BILLING ADDRESS <br /> BUSINESS NAME Y V/A�\/t l,nC/L., .. IAA a PH,7ONE# ExT. <br /> HOME Or MAILING ADDRESS l 1 VY I f vl FAX# <br /> tQ ly0 ( 1 <br /> CITYzf4 N STATE <br /> ZIP �5 q, q <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,Standards, STATE and F. ERAL laws. <br /> APPLICANT'S SIGNATURE: �__ DATE: h oC <br /> PROPERTY/BUSINESS OWNER❑ F.RATOR/MANAGER OTHER AUTHORizED AGENT El <br /> If APPLICANT is not/he 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 AL Uie same time It Is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ' Voj COAD <br /> COMMENTS: (� ��p ` •1,,t ti n , ^ -�,i /�.'yn�, <br /> SANJOA, �Q <br /> COU -� <br /> � II HEALTH pE ' TNT <br /> ACCEPTED BY: y. EMPLOYEE III: DATE: C5- <br /> ASSIGNED TO: II EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Cko PIE: <br /> Fee Amount: N� Amount Paid 15 a Payment Date hq <br /> Payment Type Invoice# Check# cto 10 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br /> i <br /> L <br />