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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> uLT <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 5 VA^1f OAl CAL <br /> FACILITY NAME <br /> ✓ O QC IRA?-'EC O WL 1^14 <br /> SITE ADDRESS9SsI E yKrcyIAJS69 � t'►7A n/7-G e/A <br /> Street Number Direction Street Name Citv Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> SAr- Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (.47 ) 1 -2<-7 ;?4-o-4o ICA' - 1-4000z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Dew <br /> c—S <br /> rr CHECK if BILLING ADDRESS <br /> G <br /> BUSINESS NAME PHONE# EXT- <br /> F CaNSVI r/A/c - <br /> HOME or MAILING ADDRESS FAX# <br /> O (Z° ) GG —a2 <br /> rc- <br /> ITY K2LOGlL / <br /> STATE e% ZIP S3 Bl <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 ENvrRoNmENTAL 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, ATE and F L laws. r f <br /> APPLICANT'S SIGNATURE: DATE: <br /> 1 <br /> PROPERTY/BUSINESS OWNER❑ OPE OR/MANAGER ❑ OTHER AUTHORIZED AGENT 181. <br /> If APPLICANT is not the BILLING PARTY,proof of 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 /> TYPE OF SERVICE REQUESTED: A//T- D IA16 1I.Pig, u 7,qL <br /> COMMENTS: <br /> MAY 2 0 201 <br /> -'e' /ZII1,� ��.,� <br /> 40 vF (how..S`o SAN JOAQUIN COL NTY <br /> ENVIROMENTA <br /> HEALTH DEPARTM ENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: �— Z <br /> ASSIGNED TO: ��-L�t C j EMPLOYEE#: DATE: <br /> Date Service Completed of already Completed)' SERVICE CODE: P/E: G(�� <br /> Fee Amount: Amount Pai aSO� Payment Date S l <br /> Payment Type Invoice# Check# 3,317 Receive By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />