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s 0 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Properly FACILITY ID# SERVICE REQUEST# <br /> I_IQVUK SuRC-4`6AS STkTitN / LJ�nO 3-1 -- S 2co73S-4S <br /> OWNER/OPERATOR GOVINDTD S'INII) II ATt' AL <br /> tit1 1tl; 7` µt-{-- CHECK If BILLING ADDRESS <br /> FACILITY NAME P L Pa A �,U(v O R * 1 <br /> SITE ADDRESS OQ S c—HERV <-6 LN 1--091 g52—L-.10 <br /> Street Number Direction Street Name CI ZI Cad¢ <br /> I'JME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> (20`►) 53"1 1840 <br /> PHONF#2 Ext. BOB DISTRICT LO CATION CODE <br /> (� ) 368 012 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CAOV1 N-�� S. / TAjal <br /> r^L�' C. Id l ii1� CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME 1 "-M L aw, 1 PHONE# 5 I0 4 O Ext. <br /> HOME Or MAILING ADDRESSS' FAR <br /> 8 00 �G <br /> q) 3 6 `61 z 7 <br /> CITY �LI (J 1 w '�'V STATE C /I_ ZIP `(3/ <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 Or <br /> activity will be billed to me or my business as identified on this form. <br /> also certlry that I have prepared this application and that the work to be performed will be done in accordance with all .'AN JOAQUIN <br /> COUNT Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �j �cti�{f &,re,,9 DATE: <br /> PROPERTY/BUSINESS OWNER E3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is n t the BILLING PARTY proof of authorization to sign Is required Title <br /> AUTHORIZATiON TO RELEASE INFORMATIOi;. When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMEN rAL HEALTH DEPARTMENT as Soon as It IS available and at the Sarnp�jQI�ILI r(} dEd :o me o, <br /> my representative. r+A% � <br /> TYPE OF SERVICE REQUESTED: u ` C&,Y� 7av,- <br /> COMMENTS: NUV V 6 LU'J <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: t <br /> ASSIGNED TO: ,fyr/t S )0169 <br /> !' EMPLOYEE M DATE: f � r 5- <br /> Date Service Completed (if already completed): SERVICE CODE: CC� l P/E: ZJ?(I <br /> Fee Amount: I Amount Paid -3 CI C9 0Payment Date f S <br /> Payment Type G Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />