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0 • <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CHECK if BILLING ADDRESS <br />FACILITY ID # <br />LQ�or�a Y <br />SERVICE REQUEST # <br />00E- Keseo.rrzk Fae; /:+y <br />ASSIGNED TO: <br />FAX # <br />(`t2S) Ili -9Y75 <br />clrY L. r V e v, #"Ore. <br />E ZIP 411 <br />s�►tj 5s r <br />OWNER / OPERATOR <br />� <br />De a,etwtentoF Eller y � /VASA <br />Amount Paid <br />CHECK If BILLING ADDRESS <br />FA IUTY NAME <br />Lav`►ren¢e L±Verwtore N4fiion4) <br />La bOrC4 Ory S i fq 300 <br />Invoice # <br />SITE ADDRESS <br />ICcrro.1 <br />I <br />A o I' C W n 00ATr <br />4 Gy <br />95 376 <br />Street Number <br />Direc <br />Street Name <br />i <br />zi <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />7000E4 <br />s � f - A v e n a e <br />L. -G Z 7 <br />Street Numbe► <br />Street Nam <br />CITY L- I v e r wta ✓ e <br />STATCAE <br />Z9 H 551 <br />PHONE #1 ExT• <br />APN # <br />LAND USE APPLICATION # <br />OZ5) LiZ3-!062(a <br />PHONE #2 ExT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR �` j� <br />,J O f e i t 14 CJ q <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME..bN <br />Lawrence L:ver/rtore NQf":ona1 <br />LQ�or�a Y <br />PHONE# ExT• <br />945 IZ3.7/73 <br />HOME or MAILING ADDRESS <br />7000 IEasf Aven%e L -69S <br />ASSIGNED TO: <br />FAX # <br />(`t2S) Ili -9Y75 <br />clrY L. r V e v, #"Ore. <br />E ZIP 411 <br />s�►tj 5s r <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, Standar s, STATFt an�;pERAL 1 S. c <br />APPLICANT'S SIGNATUR �-7 V�r "�DATE �f 7— o / <br />PROPERTY / BUSINESS OWNER f'JCP0PERATOR7e MANAGER OTHER AUTHORIZED AGENT ❑ <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 the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: ESIR L)POPO4Df c Xii* 144'" CON4✓Ot49 is qii FA ens;ObLor Aew S'Ce ' i <br />Healy CfeQNAir SN(�e✓4ierr qNc{ rcp14ce �)Ci� 1 +r►9 J;sp&Ksees w',f 6 naw WayNt' <br />Rel i olce lispenSer's a4f 8o;1J,'n9 879. No PaNt'I�a'l'io„s ik'1'o ♦No sides •r <br />butt aI"I .; fke +vJ0 4xist;n9 UpGa w'+�� bL M 4 J 4r. . <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />ej <br />