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SAN JOAQUIN CnUNTY ENVIRONMENTAL HEALTH P"ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '11,16d'IT <br /> OWNER/OPERATOR <br /> C L / /^) �� �J � ) BILLING ADDRES' <br /> FACILITY NAME /f —� / <br /> C• ,v T G v <br /> SRE ADDRESS 5 / SOJ% �G /'O/�t J)0 <br /> Street Number I Dimclion treat Na a CIN ZIo Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �� v� OZ-/) ac)D,) <br /> Street umber Street Name J <br /> CITY �� STATE ZIP 5✓/ f <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# O( <br /> (Yah /& <br /> PHONE#Y / '>' EXT. BOS DISTRICT ATIJN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �- <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT <br /> 6t J/L /,,ic, 6 /7S <br /> HOME or MAILING ADDRESS FAR# <br /> CITY STATE G,IJ ZIP <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 rd tF, / <br /> or lr be erfomed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE az S. <br /> APPLICANT'S SIGNATURE: DATE: / <br /> PROPERTY/BUsINE55OWNER❑ ERATO /MANAG ❑ O ER AUTHORIZED AGENT <br /> ljAPPL/CANT is n th B/LL/NG PARTY pr jojauthayi at, <br /> to sign is required Title <br /> AUTHORIZATION TO REL E INFO ATION: 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. / C /� r <br /> TYPE OF SERVICE REQUESTED: ZF/✓ X U !r/ J K—S <br /> COMMENTS: r PAYMEN <br /> RECEIVED <br /> SEP 11\4 2010 <br /> SAN JOAC UV COUNTY <br /> ENVIRON NNNNNN111IIIENTAL <br /> HEAT.TH DEPARTMENT <br /> ACCEPTED BY: U L_i ,)F— t EMPLOYEE#: 2�/ DATE: 'C / T (G <br /> ASSIGNED TO: V(D L�.� EMPLOYEE#: 7317 l DATE: 4/1 t f fo <br /> Date Service Completed (if already completed): 1 )SERVICE CODE: (&3 P I E: 3u <br /> Fee Amount: i t L(-(0 Amount Paid N LA �1A Payment Dae oI 1 L41 ( 0 <br /> Payment Type L, Invoice# Check# 3 S Received By: Vr�r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />