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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACII-ITY ID# SERVICE REQUEST# <br /> FA 050 U323 13QWy' <br /> OWNER/ OPERATOR v1 `,�V1 � O <br /> �t5�t yaiav� �I� �A�,J CHECK If BILLING ADDRESSO <br /> FACILITY NAME M(IVZI SCOS ,�7tA A u r� I � <br /> SITE ADDRESS 3 550 `� Y W t SO✓1 O` '1S20S <br /> Street Number Directlo tee e 1 1^ C 21 Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 30LA t--J Y40 I l I,) 'Dr - <br /> Street Number Street Name <br /> CITY IYA/ STATE r ZIP `153� <br /> PHONE#1 t �,//fit /fi <br /> EXT. APN# LAND USE APPPLICATION# <br /> (%n) 2 33 <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR J <br /> t�/t1f/C� /^ p ` a /CHECK if BI�L,.LIINGADDRESS <br /> BUSINESS NAME l " `701� W� l Vrr, Lll!i�\\\ cA POI —A d-�L PH 42 I_ <br /> ("1- EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY R)LILi STrAT 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 FEDERAL laws. <br /> APPLICANT'S SIG NATURE: G If DATE: I O-1 — 2O <br /> PROPERTY/BUSINESS OWNER OPERATOR ANAGER ❑ OTHER AUT ORIZED AGENT❑ <br /> IfAPPLICANT is not the BLLLING 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: fW1U Y lJ P <br /> COMMENTS: <br /> MARLA/ 10� 4 VqW7 CZ, n <br /> 1\ oCr o 7 <br /> '9AN JO <br /> 20?0 <br /> " THOHMEN UN7y <br /> ACCEPTED BY: Y1A ,/1 EMPLOYEEM DATE: T <br /> ASSIGNEDTO: l r J EMPLOYEEM DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: 0 ` PIE: I <br /> Fee Amount: 0 (C7 Z' Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />