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a <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />eeoscD el'9VV41 / <br />FACILITY ID # <br />L 3.Y. -'miff -- 4o S <br />SERVICE REQUEST # <br />OWNER / Gift" fTi511 <br />p — �.+djoCHECK BILLING ADDRESS <br />i✓ <br />FACILITY NAME✓V o'!C//Crr %?4J- /� `/(%✓ �i'Q���/!�`J/.UG ��l e- <br />SITE ADDRESS —?//3o <br />Street Number <br />e'04 - <br />Direction <br />e�/ wr- 1*7—LU7kJ k4i <br />Street Name <br />�1,11FA✓---f <br />city <br />95'.3 77 <br />Zip Code <br />HOME or MAILING ADDRESS (if Different from Site Address)/ d �o <br />Street Number <br />(� 74r' -L./ <br />Street Name <br />ZIP �O c <br />CITY „�. / STATE elf••7 <br />PHONEq#1 EXT. <br />(„2v/) 4149W <br />APN # LAND USE APPLICATION # <br />® l0 <br />PHONE #Z EXT• BOS DISTRICT -�f7LON <br />( ) <br />OCATI CODE <br />CONTRACTOR a REQUESTOR <br />REQUESTOR , ` �L �- <br />!^' <br />COMMENTS: DRI U IA✓lj ?CAI -117 Q <br />®f/moi-07 . <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME /�� ilb� Cy/�j„//� ��OZ�O <br />PHONE# <br />ExT' <br />FIEiME-Qr MAILING /4DDREss Da ® / G / <br />! 6 <br />FAX <br />")#9) <br />f f —' ?0 ] 1 <br />CITY �'gez'p— 70?L-1STATE <br />t::;:4 <br />ZIP '�q `$- 2—,{y7 <br />BILLING ACKNOWLEDGEMENT: 1, 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 FE RAL laws. <br />APPLICANT'S SIGNATURE: DAT���Eyyy �0 7 __ / <br />PROPERTY / BUSINESS OWNER ❑ 7 OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT �� �Vd ` ClA-lG e,V �' <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: <br />COMMENTS: DRI U IA✓lj ?CAI -117 Q <br />®f/moi-07 . <br />ACCEPTED BY:r� ,� <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: ^< <br />EMPLOYEE #: 40480DATE: <br />111 /® <br />Date Service Completed (if already completed): ///2�% <br />SERVICE CODE: <br />P I E: <br />Fee Amount: <V <br />Amount Paid <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />1 <br />