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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICEEQUEST# <br /> �II/�I <br /> • OWNER/OPERATOR <br /> Le-z CHECK If BILLING ADDRESS <br /> FACILITY NAME MCi s fires (��o s n I <br /> SITE ADDRESS 2 cJ� �A/ 1 r' lQ Cl QUQ <br /> Street Number Direction J- a 1-1�'�l "1 ZI Cotle <br /> HOME or MAILING ADDRESS (if Different from Site Address) 2 Q —7 a <br /> street Number - vV , Street Name l.l� <br /> CITY E ZIP <br /> PHONE#1 t" 1 EXT. APN# LAND USE APPLICATION# <br /> (a)R) u50-3�tCO0 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> (201) Zoo-23go <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �i ^���— CHECK If BILLING ADDRESS <br /> BUSINESS NAME I'S —Fres ` D��O73 PHONE# Ems' <br /> / _ ` I '1 N5u31-fro <br /> HOME Or MAILING ADDRESS,,_,,, FAX# <br /> 7 Q."U 1Oavl�C ( ) <br /> CITY \7 STATE 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 JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATUR!1E �7�a� L G CJ p tel(e� DATE: I - I�j 20 <br /> OPERTY/BUSINESS OWNERysPP7OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> IjAPPLICAN/lT 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`ass'e" ssment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the psry a It is <br /> provided to me or my representative. Re'%I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: J <br /> J <br /> /( II// 1L <br /> Tian c;M c vC C4,QIJIN DDU�� <br /> ACCEPTED BY: I t V EMPLOYEE#: DATE: <br /> ASSIGNED TO: !• V�1 C ' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI I E: I� <br /> Fee Amount: - Amount PIP 756 rv29 Payment Date /�— <br /> Payment Type Invoice# / Check# Rece' ed By: <br /> EHD 48-02-025. SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> � �q ZI <br />