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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER/OPERATOR . ' 1 I CHECK if BILLING ADDRESS <br />. WI ' II o <br />FAcury NAME i j <br />WC/fere : el) ..,- ,-,, &tor ( E <br />SITE ADDRESS <br />Street Number Direction Atalitne riC i (- eet Name <br />5 Joe /-0 r • <br />City <br />CrS2. l c( <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number Street Name <br />CITY STATE ZIP <br />PHONE in ExT. <br />( ) <br />APN # <br />V/ i — -7.4) O - " f <br />LAND USE APPLICATION # <br />PHONE #2 Ext. <br />( ) <br />BOS DISTRICT <br />0 <br />LOCATION CODE <br />CTOR / SERVICE RE UESTOR <br />REQUESTOR li <br />,-//cCtrirl. A4 CO--eiV-\ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME 1.. Li (ge if <br />/5 P001 0'4; e *7 - gni <br />PHONE # EXT <br />(Z°') cSa - gv-13 <br />HOME or MAILING ADDRESS 1 <br />(. 0 (.& . . ,- F runrc, cle- h 11 <br />FAX # <br />( ) <br />Crry B if poil STATE cd4 zip ci 536 6 <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 FE ERAL laws. <br />APPLICANT'S SIGNATURE:DATE: 2/V ILI 7 <br />PROPERTY / BUSINESS OwNERD OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT IS <br />ifAPPL/CANT 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 aitthe same time it is <br />ifEb;Pfilltr. <br />TYPE OF SERVICE REQUESTED: ref"fr?..._ Et ,C-p...Cit t -C-1777- cal/kb <br />COMMENTS: <br />g gr a.45 1 <br />841k41404 01,1 <br />I i 9 <br />P•41?ti,;.24 ' r <br />ACCEPTED BY: i 1,1 < ,A/1/31 /2.--t.-.. EMPLOYEE #: 2 t, 7 0 DATE: 216 if c_i_ <br />ASSIGNED TO: /JOU (A) 1‘,..e.").e4v-i et,..4,-, EMPLOYEE #: 53 6 -7_ DATE: <br />elp4e,Service Completed (if already completed): SERVICE CODE: 7_ 2_ PIE: 3 t, 0 z <br />,owA'11171 Amount Paid .„.2.6(9,1)O Payment Date <br />y4 it invoice # Check # 7 //x , Received By: <br />4 <br />EHD 48-02-025 <br /> " <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003