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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> lft. SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> >SZ SS 2y <br /> OWN R/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> �( <br /> FACILITY NAME � <br /> �2tSN 1ZDNLl'fS YCE CXi5,411II <br /> SITE ADDRESS WF.�T ���-I-1 S p,EFY "��AC�/ 9537 <br /> 127q Street Number Direction street Name Ci Zip <br /> t( HOME or MAILING ADDRESS (If Different from Site(Address) <br /> 3ogq � / <br /> . 2AL 6)Vd 7r �L(� Street Number Street Name <br /> CITY <br /> Ti2Rt SCA 953"76 <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (zI-9) 87q - 390.S- <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS13 <br /> BUSINESS NAME <br /> PHONE# ExT. <br /> HOME Or MAILING ADDRESS FAx# <br /> CITY 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 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 be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURI ,I✓fit lGw DATE: Zz-'1ZDg <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLLNG 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 <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 /> TYPE OF SERVICE REQUESTED: RECEIVED <br /> COMMENTS: ,74O -'/— OCT 2 1 2008 <br /> SAN <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: - EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEEMI W%qkiF9r <br /> DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: / PIE: Y <br /> Fee Amount: OS "a Amount Paid $ pS.& Z) Payment Date to <br /> Payment Type CASkt Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />