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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5020013-7iZ <br /> OWNER/OPERATOR <br /> G-6 ( CHECK If BILLING ADDRESS <br /> / V <br /> F I �s� � N��I-,✓ <br /> $ITE ADDRESS j y <br /> Street Number Olreclion Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) .21 1 LP c (f_ L f(� A li - <br /> �� <br /> Street Nu, <br /> bar Stmet Name <br /> CITY - n Com` STATE C ZIP t <br /> -PMOyE#; ' v�N�A�C EM. APN# LAND USE APPLICATION# 1L' <br /> I//Or.2 <br /> PHONE#2 F-xT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> (✓ J 1 U '�I CHtE�CK If BILLING ADDRESS <br /> BUSINESS NAME O _ 0 ��i GJ t, "if <br /> J` / .G' O P(7r*# CON <br /> 1` I G I� EXT. <br /> HOME r ILIN?D RESS r _I r FAx✓1# `� <br /> If ) <br /> CI Y /,f STATE 61-f ZIP 2 <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 SIGNATURE: (/fj x. DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANA�\OTHER AUTHORIZED AGENT 11 <br /> If APPLICANrisnottheB/LLtyGPARTY 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+XCMMrfe it is <br /> provided to me or my representative. 0r� <br /> TYPE OF SERVICE REQUESTED: Y� CAAMLz <br /> COMMENTS: \\ MAI <br /> E <br /> VI06 OA VlS�vtc� JAllz �w1S%VO <br /> SANJOAQUINENTAL IiEALfH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: 2( Z <br /> ASSIGNED TO: S' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: -.5Z3 'x: 1100 <br /> Fee Amount: 5 _ Amount Paid Payment Date 24 <br /> Payment Type Invoice# Check# Received By: _ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />