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SAN JOAQ- I COUNTY FN'%iR0NMENTAL HEAL 1 DEPARTMENT <br /> SERVICE REQUEST lq.s <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR / <br /> P(S S OLl Ps \ED �,rJ GI fv�El2-I tJ�r� �DR YPtTV DE��L fntiC CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �/_ C I Zd SS3�- <br /> Street Number Direction Street Name citv Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) -4 ZD(V 1-�C wt-J O L..D&I -c>9—.Street Number Street Name n <br /> CITY D D�s r a STATE C A 9 <br /> ZIP 53 <br /> PHONE#1 EXT. APN# LAND USECATION# <br /> ( 1-6-1) zvq- 6 3 --- � L9 <br /> rJI�rL$2 EXT. RQ$DISTR!CT LGCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR t4 bpi CI4ECK If BILLING ADDRESS <br /> iA ��►a.oNrnEN-fA�L � At3►GI�1� RP�cc-v <br /> BUSINESS NAMEPHONE# EXT. <br /> pJ 0�Pr �1^►vl RorvmEr�TPtt_ yon 3to�-3--o 1 # 38 <br /> HOME Or MAILING ADDRESSFAX# <br /> 2z, t�o�s t�►.1 L.t�l. ( Zo°I) 3(nq- �ZzB <br /> CITY L.•0 D STATE C 1p� ZIP <br /> BILLING ACKNOWI,EDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTti 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,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: i�WE'MFT-tom (O _ <br /> PROPERTY/I3ltSINESS O\VNEIi❑ PFRATOR/MANAGER El OTHER AUTHORIZED AGENT ® <br /> If APPLICANT is not 1 r ILLING 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 /> of ... -1t - ..1... aala nni!ar asscEsrnenf <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: S LA f t k C IP S u S t c- ) PA EwE� <br /> COMMENTS: 0 ZN3 <br /> /W / --.4 f �pv 1 <br /> L- �oAoul�coup <br /> r SAN�/,,�/ ��,b �• <br /> HV DEPARTM W <br /> - <br /> APPROVED BY: EMPLOYEE DATE: <br /> ha 14 <br /> ASSIGNED TO: EMPLOYEE#: / I DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 31S P i E: a, <br /> Fee Amount: I v Amount Paid Payment Date (OZ� 3 <br /> Payment Type r V Invoice # Check# SSG -Z' Received By: <br /> EHD 48-01-025 ov.wa\l. SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />