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'1 4 <br />Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />",--.1 r-.•,, ,r- (-\ -1 <br />FACILITY ID # <br />-- t." PO "? t ) Z )6.- <br />SERVICE REQUEST # <br />-20051/4 1 6) <br />OWNER! OPERATOR ,c• CHECK if <br />J e c /14 , ,, 4 b,. , BILLING ADDRESS <br />FACILITY NAME „.• <br />i f --,1 Pt <br />SITE ADDRESS i l i‹. Street Number Direction <br />L i Fe g 4. y / <br />Street Name <br />/11,-4- e c,--, <br />CRY <br />9 S 3 1 <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 Err. <br />(L1() -) , `) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Err. <br />( ) <br />BOS DISTRICT 1.-;-_, <br />L.) <br />LOCATION CODE <br />CONTRACTOR / SERVICE RE UESTOR <br />REQUESTOR _ <br />/9 (7 c,--, , / ...> <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME '.z.,-1‘ / /0 ( b,, /(4,-- 5 <br />PHONE # <br />( Lk .)( ) <br />EXT. <br />HOME or MAILING ADDRESS <br />,,/,-/•,C,`-,/ <br />Fax # <br />Cry .., , , STATE ("LI ZIP 9 s ii z <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 • A FEDERAL laws. iii <br />..40 <br />TOR/ MANAGER 0 OTHER AUTHORIZED AGENT <br />IJAPPLICANT is not t LING PARTY proof of authorization to sign is required <br />AUTHORIZATION TO RELEAS 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 availplAyMettrame time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: Cf•CCIL-- 14=VIGII V <br />COMMENTS: sEp i 0 202I <br />JOAQUIN COUNT? SAN timENTAL ENVIRO ..........1 <br />viEALTH DE.pAR i NI PI <br />ACCEPTED BY: 1, EMPLOYEE #: 6,2 / 3 DATE: ci I to 121 <br />ASSIGNED TO: EMPLOYEE #: c7 k,z- DATE: et ( to( 24 <br />Date Service Complet (i already completed): SERVICE CODE: 52 `3 P 1 E: I LO ( <br />Fee Amount: <br />41-5t <br />Amount Paid it 51 Payment Date G 4)/ / <br />Payment Type <br />ilLS <br />Invoice # .c.11‘Cli # 1 ( 57ji i s---r.. Received By: <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 <br />DATE: <br />SR FORM (Golden Rod) EHD 48-02-025 <br />REVISED 11/17/2003