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SAN JOAQUIN ,. ,dUNTY ENVIRONMENTAL HEALTH 1. ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />COMMENTS: <br />m <br />HOME or MAILING ADDRESS Ae 3 <br />bei/� <br />OWNER / OPERATOR <br />( orb 3 s/ <br />CITY / /rJ /- STATE - ZIP 9,5--2141 <br />vv <br />CHECKHBI IN GORES <br />FACILITY NAME ^r %jr a J�L/ <br />SITE ADDR SS <br />3 / <br />I ` <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Stroel Numtrer <br />DireCf(on <br />ASSIGNED TO: <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Numbar <br />Stroot Name <br />CITY <br />STATE ZIP <br />PHONE #1 E.. <br />(&i) $L©® <br />APN #' <br />- b <br />LAND USE APPLICATION # <br />PHONE 1 Ezr. <br />BOS DISTRICT <br />LOCATION CODE <br />invoice # <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR D—i;71 CHECKNBILLINGADDRESS0 <br />l L .JC . <br />BUSINESS NAMEPHONE# <br />a2 ✓c. <br />ExT. <br />COMMENTS: <br />m <br />HOME or MAILING ADDRESS Ae 3 <br />FAX# <br />.5— <br />( orb 3 s/ <br />CITY / /rJ /- STATE - ZIP 9,5--2141 <br />vv <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 performed will be done in accordance with all SAN JOAQUINCOUNTY Ordinance Codes, Standards, STAX7E' <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/BUSWESS OWNER❑ OPE TOR/MA GER THERAUTHORIZEDAGE <br />IfAPPL IC4Nr is the I IN <br />PAR proof of au t orization to sign is required Title <br />AUTHORIZATION TO RELEASE I FORMATION: When applicable, 1, 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. <br />nI r <br />TYPE OF SERVICE REQUESTED: ,S <br />,/✓Idle/' <br />RECEIVED <br />COMMENTS: <br />AUG 15 2007 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />ASSIGNED TO: <br />Date Service Completed (If already completed): <br />MBY': <br />Fee Amount: &V <br />AmoungZgPaymentDae <br />tDaPayment <br />Type ✓ <br />invoice # <br />EHD 48-02-025 <br />REVISED 11/17/2003 SR FORM (Golden Rod) <br />