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titULIVEL) <br /> FEB 2 6 2014 <br /> SAN JOAQUI,. COUNTY ENVIRONMENTAL HEALTH LiEPARTMENIENVIRONMENTAL <br /> SERVICE REQUEST HEALTH DEPARTMENT ' <br /> • Type of Business or Property FACILITY ID# SERVICE R QUEST# <br /> OWNER/OPERATOR <br /> RZ-_ CAJi: I � CHECK if BILLING ADDRESSI� <br /> FAciurY NAME oil * 111 <br /> SITE ADDRESS IILr,0 JZUr� <br /> SVeet Number Direction D� V V C I 'o Jt CUdJ <br /> HOME or MAILING ADDRESS (If Different from Site Address) I LP rn{��r^'�1yn 11 - <br /> Street Number � 1 _ �aet Nama <br /> CITY SbUWA N , STATE n 1 ZIP <br /> PHONE#1 W1 APJ# 1 O LANG USE(APPLICATIONAP # <br /> PHONE#2 Exr. BOB DISTRICT LOCATION COOS <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -'t <br /> CHECK if BILLING ADORE S�' <br /> BUSINESS NAMET h u j PHf)N # DDu 2_ Ex'C�- <br /> HOMEor MAILINGADDRE33 1 K �GNet <br /> '*11 <br /> CrrY <br /> VV I) no � STATE 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 or <br /> activity will be billed t0 me or my business as identified on this forth. <br /> 1 also certify that I have prepared this appli nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA a d EDE laws. <br /> APPLICANT'S SIGNATURE: DATE: Le 3 <br /> PROPERTY/BUSINESS OWNER OPERA /MANAGER ❑ OTHER AUTHORIZED AGENT _ <br /> If APPucANT is not#re Bluln� 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 environmentallsits assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: S` 3 1P� a' +p <br /> COMMENTS: (J rlo F3 <br /> Pub' 1 Govvf <br /> SAN JO 0111 t•1TA1� <br /> %aWIA DVPARStN <br /> ACCEPTED BY: � �R7 ` EMPLOYEE#: ZC"�1�.U�r DATE: <br /> ASSIGNED TO: 4 EMPLOYEE#: 5 Q U DATE: <br /> Date Service Compl ted (if already c pleted): SERVICE CODE: v e-) 3 PIE: '�3p <br /> Fee Amount: Amount Paid I Payment Date ,l <br /> • Payment Type Invoice# Check# /x) Re ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17(08 i <br />