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SAN JOAQUill COUNTY ENVIRONMENTAL HEALTh JOEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />CO, <br />FACILITY ID # , <br />F,4- 60605-.8 7 <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />CHECK if BILLING ADDRESS <br />NAME C-- M k ....N iD1/4._ ,ND FACILITY D c <br />. :__...) n <br />SITE ADDREI -7 0 <br />1 Street umber Direction VV\ k StrCeetZ <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOH <br />0 <br />A CHECK if BILLING ADDRESS <br />BUSINESS NAM s Exr. <br />TN4#)cl-e_s-YLfc-f-.s, <br />HOME or MAILING ADDRESS ,S? / D' 6, two se Fl (% ) °‘2.4--1 q 70 <br />ciTY <8Wr-C._42— i7 --//`-'\ C.1---VV-6) STATEC_A_ ZIP <br />BILLING ACKNOWLEDGEMENT: 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 applic on and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, ST TE nd FEDERA laws. <br />DATE: <br />PROPERTY / BUSINESS OWNER0 OPERATOR / ANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY; 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 at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: I /66 k.e79/ OZ)--/ dn,,,, AI r rt.,7Eil <br />COMMENTS: Q. Df 7 A- 4-- \I CT. (t- IEC E-IVIE , <br />MAY 1 8 ? <br />-"1-T71 0 tM7:44 6PARrift. <br />ACCEPTED BY: Le 462E- EMPLOYEE #: Li 1) SI— DATE: 57// SY/ <br />ASSIGNED TO: P&Z)/2-0 27--/92— EMPLOYEE #: z,..) 2 _ 1 .3 DATE: 5lig-li 7 <br />Date Service Completed (if already completed): SERVICE CODE: ----2.._ 2_ PIE: <br />Fee Amount: 2_6---O c,c> Amount Paid c._.L, Payment Date 1-71 g) / 2_. <br />Payment Type / <br />v' <br />Invoice # Check # Received By: LZ <br />APPLICANT'S SIGNATURE: <br />EHD 48-02-025 <br /> SR FORM (Golden Rod) <br />REVISED 11/17/2003