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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S�c0-7? <br /> OWVEK, OPEII aTOR <br /> CHi.CK;:BILLING ADDRESS❑ <br /> F;-.Ivry NAME <br /> SITE ADDRESS C4 <br /> Mill9­S131 <br /> L7 itrcet Number Utre_tion._ �y t rStreet Name_ CIN I ZIP C.de <br /> HDi,:E0; IAII iADDDr-SS "fi.,ffer r`,\n ,teAd('rress; <br /> 6 G �1Tti>iJ Street Number Str et Name <br /> ^.ITY STATE C r, ZIP 9 <br /> PHONE#t Exr. APN# LAND USE APPLICATION# <br /> ,'HONE#2 TXT• BOS DISTRICT LOCATIO E <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REgUESTOR <br /> S U,!G�tA� r l..Jt r i— 1 L— CHECK if BILLING A00RESS® I. <br /> BUSINESS NAME VK� PHONE# EXT* <br /> _ E _�2 i4e �. o653 <br /> HOME Or MAILING ADDRESS FAX If <br /> IIF <br /> S <br /> _ �—n 5:7 +/ Lie - 7 7 <br /> n (-t ►Z� ru <br /> ( n ) 2.3 <br /> CITY <br /> El[ AJC_ ,` C�'f _t•4„r,r/ FTATE <br /> (^A <br /> ZIP q '731 23 / <br /> BILLING ACKNOVILEVGENIENT. I, th. undersigned property or business owner, operator or authorized agent of same, <br /> acknowledg= that all site and/or project speciF.; ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated With this project or <br /> a,%vity will be gilled to n,e r;r my L.Isiness as identifte-'on this form. <br /> '' also certify that I have prepared this al.Aicatio and that the work to be performed will De r1nne in accordance with ail SAN JoAoulr! <br /> COUNTY Ordinance Codes, Standards,STATE and FE_ RAS Idws <br /> APPLICANT'S SIGNATURE: l� <br /> PATE; <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ e _ <br /> If, aucANT is not IuP Ra:'h_PART', proof of authorization to sign Is required ]lite <br /> AUTHORIZATION TO RELEASE INFORMATION: , hen L-pplicable, I, the owner or opejator of the property located at the above <br /> site address, herehy r*I:tl,ori:a the release o am,e Te all a cults, gec,achnical data and(dr envfronmentallsite assessma^t Information <br /> to i SAN JOAOU!bt COUNTY ENVIROPMENTAL HEAL R'uL r .ro-:=NT as suon as it is available and at the same time C is provided to me or <br /> my represerdr ive <br /> .1v-OF SERVICE REQUESTED: _li �� Pfccin C4 cec-K {P�►A.YYMEyyNT <br /> .�iMIIIFNTS: �/y�Ly � ,'TIS'-Q jiL� Cl•'V� �J'/cS e-7-L 3 SS <br /> 11'5+`5rt"1 V{ >`Gt`\ w(J 7(z�! Jr CA,,,J � NOV `L 2 ii5 <br /> -rr`C '> �5 SAN JOAQUIN COON <br /> TV <br /> ENVIROMENTAL <br /> HEALTHDEPARTMEW <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> A-SIGNED TO: '( $ici X;l,q(per EMPLOYEE#: DATEU ?5 <br /> Date Ser!no Completed (if already completed): SERVICE CODE: ::;ctj — <br /> Fe a Amount:C'- Lith I Amount Paid G CJ, C-9 C) Payment Date <br /> Payment Type G Invoice# Check# �� Received By: <br /> EHD 4802.025 (� SR FORM(Golden Rod) <br /> 07/17/08 _1 <br />