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SAN JOAQUu.I COUNTY ENVIRONMENTAL HEALTH'IjEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#/- <br /> WR <br /> OWNER/OPERASf <br /> / <br /> T� ( O/I^ � — /.f qnDCHECK If BILLING ADDRESS <br /> FACILITY NAME u /� A I� /_.O0 Y _ 1 e /V hN'V � ,A/� �,Ov� ,1/1 r' n /T <br /> f Il/7�1 v l /• , /V`1��/v 1 <br /> SITE ADDRESS Zn J D , j / _C> /� A)T 1 �A)G \'� OIC Tt�'1�� 9;377 <br /> Street Number Direction lJ- l\t', Street Name— 1` l'S ` Ci�1 zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 6ob - l Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �O-r- <br /> � CHECK if BILLING ADDRESS <br /> BUSINESS NAME \ l/1 '\V\ PHONE# EXT. <br /> L <br /> HOME or MAILING ADDRESS Fax# <br /> ZSyo Z ELL1� WA SU1T� O ( ) 3 L! --7 4114 <br /> CITY ` STATE C A ZIP q S C�21a <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 an EDERA s. <br /> APPLICANT'S SIGNATURE: DATE: 7-1" /3 <br /> PROPERTY/BUSINESS OWNER❑ PERATO /MAN ER OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING r uthoriZation 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. <br /> r <br /> TYPE OF SERVICE REQUESTED: G`lgll RC)A;MF&nLfar <br /> COMMENTS: O}tl I,,� NDN o ,. <br /> 'V_-1 `�J N trDo' JUL 0 3 20113 <br /> SAN JOAQUIN COU TY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �f� '/� ` EMPLOYEE#: -7, v DATE: ?/ <br /> �_? <br /> ASSIGNED TO: ,v , ✓ Al, <br /> / EMPLOYEE#: / (� �O DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3 P/E: X66 <br /> Fee Amount• '3.7->, .— Amount Paid �7S— Payment Date 9j :j <br /> Payment Type Invoice#�241­) �a Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />