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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> r� �� I ��5 ► SRp� ?.� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> S to/C C AN-D SW EF7-S <br /> SITE ADDRESS Section TR��\I —795 3 76 <br /> •_I 6 1 W, Street Number Direction Street Name /C l Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> `)—O q1 ^ r f Street Number Street Name 6A'� I f aW -L-k) <br /> ' <br /> CITY ��N'J^C STATE ZIP <br /> Y C-/-) . gS376 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (3L41 Of3S -O93o <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> (10�) 832 -!i c 3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> /3 k�I n S- // 1�IJ CHECK If BILLING ADDRESS <br /> BUSINESS NAME /- 9t9tet y gQ/VCr 1A O S�EFTS PHONE# EXT. <br /> F Iv 3Lf935 - 0936 <br /> HOME or MAILING ADDRESS FAX# <br /> 291 �„ J2RISotJ LN ( ) <br /> CITY STATE CA ZIP /' 53 7 6 <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 SIGNATURE: (. DATE: <br /> PROPERTY/BUSINESS OWNER EY OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> It APPLICANT is not the BILLING 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 provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �(I <br /> COMMENTS: c4rlany <br /> �® <br /> 1 <br /> E 04 <br /> 4Eq V 0*F'01 7'Y <br /> qL <br /> ACCEPTED BY: (—CA EMPLOYEE#: R DATE: 7 / <br /> ASSIGNED TO: (V/�� EMPLOYEE#: l DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: v�J PIE: <br /> Fee Amount: a 'GU Amount Pai /S Z �� Payment Date / � <br /> Payment Type w Invoice# Check# 34 /2-5- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />