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3 <br /> SAN JOAQUIN 'UNTY ENVIRONMENTAL HEALTH' 7PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �f c�l�d S Loo55�I <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS 0 <br /> FACILITY NAME 7 / rjyT <br /> oX G7- — <br /> SITE ADDRESS 18 o I ` ( S rcl l 6 <br /> Street Number Direction Street Narne ✓ Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHON 1> $30 - as E- `�"# LAND USE APPLICATION# <br /> q <br /> PHONER ET. BOS DISTRICTCI LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> ^ ��� <br /> REQUESTOR // � CHECK if BILLING ADDRESS <br /> a� <br /> BUSINESS NAME PHONE# EXT.51 <br /> 0 -7 <br /> HOME or MAILING A"gqRESS' FAX# <br /> 13 KO Movl21 6"M ( ) <br /> CITY I I Na STATE cA ZIP 17 I'D <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned proIlierty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENT HEALTH DEPARTMENT hourly charges associated with this projector <br /> activity will be billed tome or my business as identified on th- orm. <br /> I also certify that I have prepared this applica ' t ork to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST WS. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER ❑ OTHER ADTHORIZED AGENT <br /> IfAPPLiCANT is not the BILLINGPARTY 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. / P <br /> TYPE OF SERVICE REQUESTED: @ C`� Z FCF NT <br /> COMMENTS: n' 'Y�t UK�I�I�(�CIQ L-O`.� OCT 3 0 2008 <br /> ACCEPTED BY: 0 C-[ EMPLOYEE DATE: O a OF <br /> ASSIGNEDTO: J �Jf)/L EMPLOYEEM v DATE: Q �� <br /> l <br /> Date Service Completed (if alre y com eted): SERVICE CODE: <br /> PIE: <br /> D I <br /> Fee Amount: ,,� -2-'ru Amount Paid a. O D D Payment Date O '3o p <br /> Payment Type tj Invoice# Check# �G�v Received By: ' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />