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SAN JOAQUIN UNTY ENVIRONMENTAL HEALTH I ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # <br />/-57 4---5- <br />SERVICE REQUEST # <br />OWNER! OPERATOR A _El CHECK if BILLING ADDRESS <br />FACIUTY NAME <br />SITE ADDRESS <br />4 (.0 Dio Street Number Direction <br />ADDRESS Ac- C__L4' c. Zia Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />Cry STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT <br />_ <br />LocATioi CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR—bo u3 --e ,c-c-e \\ CHECK if BILLING ADDRESS <br />BUSINESS NAME1 ‘ <br />\ \ `C,t- YA p-\ ee c \,(\ 3 Gccr\-)P <br />PHONE # <br />(wcp) <br />EXT. <br />HOME or MAILING ADDRESS <br />1 5 ( S c immNi cp co \I t_ LLtivQ-- <br />FAX # <br />«,)(0) 16.3 <br />CITY C2‘--erN do( 0.- <br />STATE C v.k. ZIP Ck \ "--1 Lk \ <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 />4 APPLICANT'S SIGNATURE: .......„/"Alvlow.11 0 DATE: fh • <br />PROPERTY / BUSINESS OWNER0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT :0241e."". 0" ejles.444 <br /> <br />APPLICANT is not the BILLING P,9RTY, 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 />_cf t <br />information to the SAN JOAQUIN COUNT NVIROyENTANL HEALTH DEPARTMENT a, soon as it is available a d at the same time it is <br />provided to me or m representative. Al- L14.10 C1L/F CEC__ . . 1 <br />C-37--)A (Dc-ak e— Cfr\ctrY Ile_. auf PAYMENT TYPE OF SERVICE REQUESTED: <br />( <br />\J _ <br />COMMENTS: 1 t4 a_ Pc-g— --Tc-- <br />vit <br />JUL <br />DATE: <br />SAN JOAQUINCOUNTY <br />DAI-ATEILEE:N7VMPIR°DNE:17:7 <br />COVE D <br />30 2°10 <br />7007/0 <br />P/ : 3 & 02_ <br />ACCEPTED BY: 0 L f J E ( elk EMPLOYEE #: 03 24 <br />ASSIGNED TO: pEs ,2,4 -z... 4 EMPLOYEE #: 4, 7_43 <br />Date Service Completed (if already completed): SERVICE CODE: ' ,..5 2.." <br />Fee Amount: it 1 I s-: vx..) Amount Paid <br />11 s - Payment Date <br />Payment Type t.,-- Invoice # Check # 1 .2_039 %.L. Received By: ive.,--- <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003