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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type iness or Property Ch'u // FACILITY ID# SERVICE R <br /> R/ OPERATOR �N�Y ���J ��Jlye /"gT/' ��%i.s� CHECK If BILLING ADDRE <br /> FACILITY NAME /4 ,0A/ JLam <br /> `?�p2M1/ <br /> SITE ADDRESS i11e �T�� <br /> Street Number Direction Street Name f f/t" 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 EXT. APN# LAND USE APPLICATION# <br /> i9i6 ) 7�4 �O92S 224�;- /;W—Cl/ A4 -0 3 -P-65 Cud <br /> PHONE#2 rI Ex . BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /'/5�u/L X45;1� <br /> CHECK If BILLING ADDRESS <br /> BUc NEcc NAr.c PHONE# ExT' <br /> —O <br /> HOME Or MAILING ADDRESS <br /> 7 � �#3 !OO/ / Y7VI)l <br /> ) <br /> CITY <br /> STATE /a4 ZIP 6�- <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authi - `ar bf same, <br /> acknowledge that all Site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated wi �oJect or <br /> activity will be billed to me or my business as identified on this form JL//V p r�h <br /> I also certify that I have prepared this application and that the work to be performed will be done in acc�tlAt�§�yy,,77th�all ZATYJOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST and FEDERAL la REAM HuUIN fONMgEIJOgU�tn!7y <br /> APPLICANT'S$I NATURE: z j DATE: <br /> P`ROPERT �116SINESS OWNER❑ PERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I]Q_ <br /> K'APPLL is not the BILLING PARTY proof of authorization to sign is requirCll/ Titre <br /> TI LEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> 0 FEie''a\r1t�pe y authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> � � offna[tiD�p tb AJ <br /> JOAQUIN COUNTY ENVIRONMENTAL HEALTH EP TM T as soon as it is available d at a sa time <br /> provi eyzo or representative. p pav-&L.� >J <br /> MUSH <br /> TYPE O R /^ /E : // /J <br /> C MENTg; /fi 5K 1THI1J/Z-/ 7->, <br /> F- q IZir <br /> T <br /> v' <br /> fDa. telt§n�vice <br /> D / EMPLOYEE#: DATE: IlaSI n' EMPLOYEE#: TE: <br /> Completed (if already completed): SERVICECODE: QLt' PIE: <br /> Amount: ,� . Amount Paid /l C) S Payment Date I Ub <br /> Type ,� ' Invoice# Check# 3 3 Received y: G. <br /> EHD 48- Iden kod) <br /> REVISED 1 7/2003 <br />