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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 'n/ FACILITY ID# SERVICE RErrQUESUT# <br /> {�c�or�0.�� 5 ICeS e41ur0.1� � 'SR,Gq� )c"I I <br /> OWNER/OPERATOR ` <br /> YV`C, 0tA-M` O aa . 0..K V 00. U 1t1, CO V w CHECK if BILLING ADDRESS <br /> FACILITY NAME IAA G71OK0.�V rj <br /> SITEADDRESS ---yj� VVDire}AJ <br /> Streel Number ction I/O l Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) /it O 7_ G-7e OraC,�OW M P(GLc•� <br /> J'`TT <br /> StreetNuber Street Name <br /> CITY STATE zip <br /> 5 +oc l=-Fo GA 15 7-C) <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (Zo ) R -IZZS <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> $e4-- $a r re Pro eaf bLla r CHECK if BILLING ADDRESS <br /> BUSINESS NAME • EXT <br /> f,V\ l v.cor oro. d (H #) Z(o? <br /> HOME or MAILING ADDREdS FAX# <br /> f (o (-�• <br /> 5k&w Ave. STE 101 <br /> ( ) <br /> CITYR N O T TE zip <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 <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 JoAQutN <br /> CouNTY Ordinance Codes,Standards, STATE and FEDERAL laws. any/ <br /> APPLICANT'S SIGNATURE: � y- DATE: " ( ZS <br /> PROPERTY/BUs1NESS OWNER fPERAT41t/MANAGER OTHER AUTHORIZED AGENT t4ecf-ef leeto4 <br /> If APPL/CANT is not the BLLLtNG PARTY Proof Of authorization t0 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 environmentaUsite 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 SERVICER D: <br /> COMMENTS: RECEIVED <br /> As 2 8 20V AUG 2 8 20V <br /> �Mnaodr <br /> ENTAL EWRONMENTAL HEALTH <br /> HEALTH DEPARTMENT <br /> PERMIUSERVICES <br /> ACCEPTED BY: kA l GU V'177 EMPLOYEE#: DATE: <br /> ASSIGNED TO: F OJM``rC-2,- EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 2 PIE: <br /> Fee Amount: Amount Paid /�� 6Z) Payment Date �* <br /> Payment Type Invoice# Check# I /3l Rece' ea By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />