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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK If BILLING ADDRESS <br />SERVICE REQUEST # <br />coUS <br />93 <br />HOME or MAILING ADDRESS <br />jeoo5/.5Fq <br />OWNER/ OPERATOR <br />FAx# <br />❑ <br />.1,-k E L L A O` L C O sAP A_, +, <br />^� <br />EMPLOYEE #: o <br />CHECK If BILLING ADDRESS <br />FACILITY NAME ©L � M? I A ►�( � q S <br />STATE 4 ZIP G <br />SITE ADDRESS <br />P / E: <br />im 0 F F A, -r '$ C vD • <br />!M Q 1,4 rt Ec A <br />?S-33 6 <br />ct 1-3 Street Number <br />Direction <br />Payment Type <br />Street Name <br />Ci <br />MD Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />-2--3 6 0 L I wL p '$ ea- ( l A S T- <br />Street Number <br />Street Name <br />CITY V U M, VA <br />� <br />STATESTATE C A ZIP Ct-7- 6 0� <br />PHONE #1 �• <br />APN # <br />LAND USE APPLICATION # <br />(5-30) FES- 040 <br />PHONE #2 ExT• <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />S <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME , , / Q L E ►E (K( (�1� [ „� �• , <br />PHONE # Exr. <br />ry 16 3 -)-1�-- <br />HOME or MAILING ADDRESS <br />EMPLOYEE #: 1 6'7 Q <br />DATE: O <br />FAx# <br />(,-,. Q. 0 <br />X r0 Z f <br />EMPLOYEE #: o <br />(gt6 ) 3::�3— ((} Z <br />CITY ^ ' -A- o <br />STATE 4 ZIP G <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 JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and F ERYkk <br />law$. <br />APPLICANT'S SIGNATURE: L4� DATE: (3 m <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT 0 C 0 M -T iZ X-C'-7� Z <br />If APPLICANT is not the BILLING 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 />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at #io e _time it is <br />provided to me or my representative. �E( ,T lL7�„ .IV T <br />TYPE OF SERVICE REQUESTED: <br />S <br />4116 <br />COMMENTS: <br />9 2007 <br />SAN IJOAQUENV/RoIN C <br />M " -HCpAR r_ <br />ACCEPTED BY: V�U ((� P ` 2 <br />V� <br />EMPLOYEE #: 1 6'7 Q <br />DATE: O <br />c' <br />n1 <br />fO <br />ASSIGNED TO: t j P (> (V� U <br />EMPLOYEE #: o <br />DATE: 2 _ 4� ._ <br />Date Service Completed (if already completed): <br />SERVICE CODE: I <br />P / E: <br />Fee Amount: q y <br />Amount Paid <br />'' S <br />Payment Date <br />O <br />Payment Type <br />Invoice # <br />Check # 3`� Z 2_ <br />Received By: N <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />