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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Vku-(-1 t��) ---i I S�0()� <br /> OWNER/OPERATOR <br /> .,ten L ( (] CHECK If BILLING ADDRESS <br /> m <br /> FACILITY NAME L--P5 (rye_ [, [I/ p rQ ` q <br /> SITE ADDRESS 143o �( � �- (��-C� E� �v Ci Saic+'TOIJ ,JZ`D <br /> Street Number Direction Street Name CI Zio Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) C-i Co♦?^'�L7 DP <br /> Street Number L� <br /> Street Name <br /> CITY 12AC�/ STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# (� <br /> ( !D-?I c5L( V(3`i <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ./ <br /> Lo / CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1. J t \p PHONE# Em <br /> LAS )07 <br /> HOME or MAILING ADDRESS FAx# <br /> 9c,(4 Li op, <br /> ( ) <br /> cnv -1 STATE C�� 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 F L laws. <br /> APPLICANT'S SIGNATURE: -%` � DATE: <br /> PROPERTY/BUSINESS OWNEI2L� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> /f APPLICANTisnotthe B1LL7NGPARTY 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. �r <br /> TYPE OF SERVICE REQUESTED: cN'' <br /> COMMENTS: eo <br /> DEC <br /> 142020 <br /> �V JOAQUIN COU <br /> �t N��RDONNTy <br /> ACCEPTED BY: r/1 EMPLOYEE#: /] DATE: <br /> ASSIGNED TO: wawt V� 1/('aal EMPLOYEE#: / ��3 DATE: vb J'v <br /> Date Service Completed (if already completed): SERVICE CODE: VI.F' PIE: P63 <br /> Fee Amount: J -i Ij Amount Paid / Payment Date I Z1 cf 20 <br /> Payment Type V Invoice# I ��p Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />