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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 I OPERATOR <br /> �" l ��' �a�!�{(�f► CHECK If BILLING ADDRESS <br /> FACILITY NAME L-rl/� ! <br /> SITE ADDRESS v1 <br /> Street Number Direction Street Name City 7 Zip Code <br /> HOME or MAILING ADDRESS_(1f DTenk{frrpm Site Add`r�) <br /> �(L(_A1 {U1 fv� 1 1C Y } W tr t Number Street Name <br /> CITY U `, 0 Y\ STATE +' ZIP CA 6-)1(1L) <br /> PE 1 " EXT. APN# LAND USE APPLICATION <br /> # <br /> 79) LAVA-'�SAU <br /> PHONE#2 EXT. E105 DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR1'1 r` CHECK If BILLING ADDRESS <br /> BUSINESS NAME Ij P ONE# �ID 1 Exr. <br /> V V V V <br /> HOME or MAILING AI]DRESSti.i y y VU o Q d h U l 1(} W R� C FAX# <br /> Vt� I ) <br /> CITY 5 k U CT k U h STATE ZIP v 1�2 U (p <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 a work to he performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE a DE laws. <br /> APPLICANT'S SIGNATURE: - DATE: O ' (�t(`} - 2,0 <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR I MANAGER ❑ OTHER AUTHORIZ -cENT❑ <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 and at,the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: Q e.V bl 7` <br /> COMMENTS: VIED <br /> N 08 <br /> s�,Joz�21 <br /> M ' <br /> 'JOAQUIN <br /> COUN <br /> ry <br /> �LTN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: S EMPLOYEE$♦: DATE: c` <br /> Date Service Completed (if already completed): SERVICE CODE: J P1 E: <br /> J - <br /> Fee Amount: `7Z Amount Paid f 15-a 0 Payment Date j <br /> Payment Type Invoice# GG3(� (� Received By: <br /> UV <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �ft-9"'A � <br /> 9"I ` �> <br />