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T JVE\VU11V U,VU1V 1 1 lil\YIIVVIV DI l',1V t!\L 11 L'ALt tt 11 la't\Kl IY11',iV l <br /> `. <br /> 3usfness or Property SERVICE REQUEST <br /> �b Q/L-i/LT7jfL�}� FACILITY ID# SERVICE REQUEST# <br /> R/OPERATOR .4P+j, JKG(i :- )c C � <br /> /�C�.QIJCLlTL/1JJL lqpD /✓ <br /> n NAME G �- G.LL .E'fvf f-/' CHECK It BILLING <br /> LLC- <br /> ADDRESS <br /> /77 7 E /3 /2Trj 2) C4 <br /> Street Number Dir ec lon L/ � eel Name -well CI <br /> %SZZ7 <br /> SME or MAILING ADDRESS (if Different from S(te Address) str <br /> 7e , yy LL ZI Cotle <br /> ��/K �Lr� ���/'C Street Number <br /> Ry /-� Street Name <br /> S/av STATE ZIP <br /> PHONE#I EI'T, APN# <br /> ( '//!"I - a 7 -79 LAND USE APPLICATION M <br /> Cao -/oo_p z 7 —D <br /> PHONE#2 Ems, 11 <br /> ( ) BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR /��0a� <br /> �7ry HQra/P CHECK It BILLING ADDRESSO <br /> BUSINESS NAME PHONE# EXT. <br /> �Lle Zo '33.3- 19-7Z- <br /> HOME <br /> 33- IS 2HOME Or MAILING ADDRESS FAX# <br /> P o• i3t7 s-s ( ?e o -251— X97 0 <br /> CITY ' 4fnz- STATE G� zip 9!2 Z 7 <br /> >1� J <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 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,Standards,ST E and FE AL laws. <br /> APPLICANT'S SIGNATURE: 1' DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTIIORIZED AGENTI!7 – Tile <br /> If APPI.ICANT is Not lite BILLING PARTY.proof of authorization to sign is required <br /> AUTHORI7ATION 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 /> // /�14- YMENT <br /> TYPE OF SERVICE REQUESTED: –60"'Z– � Tlcgr >' fJ'a- <br /> COMMENTS: 7 ^ j MAR 15 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> nAmount: Amount <br /> EMPLOYEE#: DATE: <br /> APPROVED <br /> EMPLOYEE#: DATE: <br /> SERVICE CODE: \ — P/E. O <br /> d (it already completed): J <br /> Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br />