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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ OPERATOR CHECK KrfVJf�t 1�l CHECK if BILLING ADDRESS❑ <br /> FACIUTY NAME R f PO/V mmt�� iYlfk' j <br /> SITE ADDRESS / 0 ti� l I/A/A/ S�� R 1 10941 <br /> Street Number Direction Street Name city_ Zip Code <br /> HOME or}MAILING <br /> �ADDRESS (If Different from Site Address) <br /> tJ�l 7x Street Number Street Name <br /> J <br /> CITY <br /> a Li STATE l 1533 ' <br /> PHDNE#1 Ex7. APN# LAND USE APPLICATION# <br /> (C7/( ) (71-11 /3 <br /> PHONE#2 Ex7• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR �Aa3/l� CHECK if BILLING ADDRESS F-1 <br /> BUSINESS NAME (� )50A/ MINI ILORi <br /> ---- PHONE# — 6, EM <br /> HOME or MAILING ADDRESS �f7 / ter, ` r FAX# <br /> CITY r\r\(V%( ,4 STATE"d ZIP 9-6-336- <br /> BILLING ACKNOWLEDGEMENT: 1, 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 FEDERAL laws. h <br /> APPLICANT'S SIGNATURE: G��- DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/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 andt the same time it is <br /> provided to me or my representative. Jam+ Y I <br /> TYPE OF SERVICE REQUESTED; q �� '/ y <br /> COMMENTS: (,. 1�G�G.rL't/ 2 .oa-v�� l�r.�/r� � SA IV <br /> J "N ?020 <br /> �IE� D,A <br /> LTH© Uq�CC UIVTy <br /> rM�NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 170�/) <br /> ASSIGNED TO: 'n EMPLOYEE#; g DATE: (ell <br /> 7 V <br /> Date Service Completed (if already completed): SERVICE CODE: I PIE:/ ?' <br /> Fee Amount: l ` C� Amount Pai �S�? D� Payment Date ZC� <br /> Payment TypeInvoice# Check# 101-7g%2 2�6 Recei ed By: <br /> EHD 48-02-025 f�5�31L�2'� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ��J <br />