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SAN JOAQUINWNTY ENVIRONMENTAL HEALTH ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ('� <br /> �L CHECK if BILLING ADDRESS <br /> FACILITY NAME V L� <br /> SITE ADDRESS <br /> Street Number irectio treat Name city 2 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 /> ( -2- - � <br /> PHONIER EXT• BOS DISTRICT LOCATION CODE <br /> 1510) 21r 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 ll <br /> &&r <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1�I A � PHONE# �fj�� •�����' <br /> HOME or MAILING ADDRESS FAX# <br /> Pu; ax C6I0CS> (`C ) el 5---366-3 <br /> CITY \3 h,-)C 1e STATE CA zip eTr'2-6,5 <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 ap ' ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TAIE an EDRM laws. <br /> APPLICANT'S SIGNATURE: . I r ' <br /> DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPE OR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPS/CANT is not the BILLING PARTY proof of authorization to sign is required Title Y <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the proper6? <br /> '"k!V216h <br /> ) <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site as <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at tme time it is <br /> provided to me or my representative. 4 200 <br /> TYPE OF SERVICE REQUESTED: us7 p U E'NVig{^QEU1N CO <br /> COMMENTS: TAL <br /> -M\ Ve �����C�CI Lei�'T Y� S 66 T -k���RTMF <br /> 5; ly DaGy- (�kSVe rx�T-,S vow.. 1e �' aceA a�%4k \o�-► r� <br /> ACCEPTED BY: LIA EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: l PIE: <br /> Fee Amount: Amount Paid 3 SPaymen ate 3 <br /> Payment Type ✓ Invoice# Check# l 0 S Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />