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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />4 <br />FACILITY ID # SERVICE REQUEST # <br />SRO(1)1 <br />OWNER / OPERATOR <br />CHECK if ---Th SEziii( -'- 5 TATioN5 BILLING ADDRESS <br />FAciLrry NAME. el-R-_-VRoAl SERVire sTAno/.1 Corn/2 -ex <br />SITE ADDRESS 9e2/5- <br />Street Number <br />IA/ <br />Direction <br />ir WALAII-(7-goe lo,e • <br />Street Name <br />7-1/0/?AiTai1 /41 <br />at)/ Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) 0:2/ <br />Street Number <br />1.PRPoR.,4rE W41 <br />Street Name <br />Cry — STATE ZIP <br />I-WE/no/yr 1:c37 <br />PHONE #1 Err. <br />(cm ) 44., gs-Yq <br />APN # <br />oz-)/-/-elo---51e) <br />LAND USE APPLICATION # <br />PHONE #2 Exi-. <br />( ) <br />BOS DISTRICT 4, LOCATION CODE 61 <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR , <br />1)0/V ctie_sivIP CHECK if BILLING ADDRESS <br />I BUSINESS NAME (J-i z), ,Aly ,ai 5etict/L7 -/A1 <br />PHONE # / <br />62e)7 ) -4-60:2 <br />Ex t . <br />HOME or MAILIN DDRESS FAX # <br />CITY --7 -1,(R STATE 01 ZIP c----3g / <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 a j cation and jilat the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards <br />APPLICANT'S SIGNATURE: <br />PROPERTY / BUSINESS OWNER 0 OPERAT / MANAGER 0 OTHER AUTHORIZED AGENT II( <br />TE and D RAL laws. <br />DATE: egki -2..2 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />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: 7 4r7 -5 0E ,5:/:w R, 0,d SA/L- • <br />COMMENTS: , ., , us ..,,... <br /> <br />q U S ital 0 . <br />ACCEPTED BY: EMPLOYEE #: DATE: <br />A <br />ASSIGNED TO: <br />' 1607eCtie; <br />EMPLOYEE #: DATE: <br />Date Service Completed (if already completed): SERVICE CODE: $73 P / E7/b0 Z...., <br />Fee Amount: q.42 , Amount Pai,d7k3‘,. ezp Payment Date <br />Receiv d By:dey Payment Type (1 ) _ Invoice # Check # 3.,71 ,f <br />EHD 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003