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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /rA030.� g 3 � u <br /> OWNER/OPERATOR -3RL�', PI Z'3-/•1 t3r9fL CHECK If BILLING ADDRESS <br /> FACILITY NAME �/j ��1n PIZ2✓} S� inn <br /> SITE ADDRESS \22?j ;� yoSern-.k > MCnvlkc� <br /> Slroot Number Dlroetion Stroot Namo cityCotlo <br /> 'HOME Or MAILING ADDRESS (If Different from Site Address) (�Izi E' A V c <br /> -2- 1 2)0 Street Number Street Name <br /> CITY] M A NTEcA STATE CA ZIP 0 & 33 -4- <br /> (PHoHE#1 J Exr. APN# LAND USE APPLICATION# <br /> 1(011W ` 7 __"I'L 200 ISv21 <br /> PHONE#2 Exr. BIDS DISTRICT �r•�� LOCATION CODE <br /> ( 1 03 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> � `REQUESTOR, Ia/1l lIrJ P2E1=T SIrj G1" .SIDI'A.� <br /> qq,"� o CHECK if BILLING ADDRESS <br /> BUSINESS NAME, ^� CILIO Q �/1'2 `PHONE# //L E><r. <br /> HOMEOr MAILING ADDRESS 2130 Frac# <br /> IT� M 41'N T-C-C-� STATE Gyp- ZIP Cl 5- <br /> BILLING <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 Coder,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURES 'li 7.-O <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGE\T <br /> IjAPPLICAAT it not the BILLINGPAR proof of authorization to sign is required Titre <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. AA <br /> TYPE OF SERVICE REQUESTED: 1/1,' R <br /> COMMENTS: <br /> '1ID 10 <br /> y Fiy(,/ROQ(pN ?o <br /> �CTyAs�&,�N?Y <br /> ACCEPTEDBY: EMPLOYEE#: DATE: <br /> ASSIGNEDTO: !Mh EMPLOYEEM DATE: �V <br /> Date Service Completed (If already completed): SERVICE CODE: 1 P/E: Q 2 <br /> Fee Amount: 'C59 _ Amount Paid �Gja,�' Payment Date -ZP <br /> Payment Type Invoice# -CWec # -:T <br /> g D I Received By: <br /> +r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 P90 <br /> �I I <br />