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��+��■i. v�Ivrr r vYtxvlvYIEINIALI1EALIIILEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S2oo 14 41P <br /> OWNER/ OPERATOR /'� <br /> C/%rnrle (p;ft-S CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> l:fo�n:a No e Fr <br /> SITE ADDRESS 73073 S �'reber••-cK /Zoa c� <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Exr• APN# LAND USE APPLICATION# <br /> PHONE#2 Ex . BOS DISTRICT _ LOCATION CODE <br /> ( ) O S G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME �r PHONE# Ex. <br /> /t!<,•rFetder lnc, a0% 9y� l3`7S <br /> HOME or MAILING ADDRESS FAx# <br /> CITY .STOG`rJ STATE ZIP <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 or <br /> 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,Standard' SA ad );E <br /> APPLICANT'S SIGNATURE: . <br /> DATE: Z41-17 6 <br /> TEJ Cn <br /> n;�e<�PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTS <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Titre <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 environmentaUsite 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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: /- �3 <br /> 6 <br /> dy%ewic. v ae.+oPc�r L, y�vSJ /� PEGS ti�06 <br /> �N�P� <br /> 30 MtW?W� t �O '(30, <br /> Np�P <br /> EN pE <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: /' U EMPLOYEE#: 03-2 DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: s2 i PIE: �`p <br /> Fee Amount: D Amount Paid 1!¢ 9 C) Payment Date (� �,� •(.� <br /> Payment Type ,�' Invoice# Check# 1;,-`/ST, Received By: <br /> EHD 48-02-025 SR FORM(GoldenRod) <br /> REVISED 11/17/2003 <br />