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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> , q97 S1Clvc q7, <br /> OWNER/OPERATOR G U p�j I h t D C—R S I^1 r` 1., CHECK If BILLING ADDRESS I] <br /> FACILITY NAME Pl-4Z:,f Ll1V4k/oilJJ 1 V tSl f"( <br /> SITE ADDRESS 01 V <br /> 5L°HE�zo%EE �,J L'00 9s1.-4 <br /> Street Number Direction Street Name CI ZI Catle <br /> 'HOME or MAILING ADDRESS (If Different from Site Address) <br /> o� I Street Number Street Name <br /> ITM Su5ANVILLC STATE C A zip q I3O <br /> PHONE#t Em APN# LAND USE APPLICATION# —1 l� <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> (530) 2 1401 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQIJESTOR I ND(r <br /> VRJ ]I N CHECK If BILLING ADDRESS <br /> BUSINESS NAME 2-A 0000F, PHONE# ExT. <br /> 1 ter' Sao 68 3 30 2 <br /> HOME or MAILING ADDRESS 106 -7 MAIN ST, FAx# <br /> / b 1 MAIN I ( ) <br /> CITY SusAtMIL' `G STATE C h zip 01c ) 30 <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 certify that I have prepared this plication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 2 S I <br /> PROPERTY/BUSINESS OWNER OP TOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BIL NG 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment Information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provi#+Atq mP(1[Wk_T <br /> my representative. �T <br /> TYPE OF SERVICE REQUESTED: U,57- de,uSU 6771' /O"Yl Ill D <br /> COMMENTS: FEb 25 15 <br /> SAN JOAQUIN C UNTV <br /> ENVIROMEN AL <br /> /j HEALTH DEPAR MENT <br /> ACCEPTED BY: '/ ��/� EMPLOYEE#: 9osy DATE: z ZS !S <br /> ASSIGNED TO: 1/ELosC) EMPLOYEE#: 22 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E:231/ <br /> Fee Amount: 136 Amount Paid �O Payment Date /S <br /> Payment Type 06- Invoice# Check# Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />