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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />Vie; �r� <br />O�S2 <br />S Leh G <br />OWNER / OPERATOR <br />HOME or MAILING ADDRESS <br />I / 0 <br />CA Q <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />e m <br />IJ <br />( ) <br />1 C l C-- <br />=SITE <br />SERVICE CGDE: 0' .Q <br />SITEADDRESS t / A ?o -� <br />�2 <br />I`^ Q rCH <br />L -110 <br />S'(_O C -IC ON.T- <br />Street Number <br />Direction <br />Check # I ZP69 / 0 c�D <br />Street Name <br />City <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />KAN DTO lJ7 <br />Street Number <br />Strest.Neme <br />CIT' I (J� <br />STATE�1 QIP n <br />T <br />PHONE #1 Ezr• <br />APN # <br />LAND USE APPLICATION # <br />(61c')6 76 606c <br />PHONE #2 En. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />?UR� <br />1.IDEi� <br />CHECK if BILLING ADDRESS <br />�HF!`Hit�� <br />BUSINESS NAME <br />VCI �. <br />�p��'loS <br />hr 4-r <br />PH?IG 6 6 6 G En, <br />S <br />HOME or MAILING ADDRESS <br />DATE: <br />FAX# <br />9 1 <br />e m <br />IJ <br />( ) <br />CITY fop,,, cy <br />SERVICE CGDE: 0' .Q <br />40- '7IP' <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 ork to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE and FEDERAL l S. <br />APPLICANT'S SIGNATURE: l7 DATE: 2I3 12 S <br />PROPERTY/ BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 0 L-Okl g4 rR— <br />IJ APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmentaUsite 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. P y <br />TYPE OF SERVICE REQUESTED: d C `�S QV'� .� Re F FN; <br />COMMENTS: VEC <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1111712003 <br />3 Z0 3 <br />N <br />1FlyDTUNTy <br />iRT,tf NT <br />11 A--,C�arp��. <br />\11SW �b Q % f -yN--c• , C-05� <br />hr 4-r <br />ACCEPTED BY: C-1 , \�/'r ✓ ��� <br />V `\ <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CGDE: 0' .Q <br />P 1 E: <br />�2 <br />Fee Amount: ou <br />Amount Paid /S� dn <br />I Payment Date ! 3 -3 <br />Payment Type dxcj� <br />Invoice # <br />I <br />Check # I ZP69 / 0 c�D <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 1111712003 <br />3 Z0 3 <br />N <br />1FlyDTUNTy <br />iRT,tf NT <br />