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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o kill n - 52da "7770 <br /> OWNER/OPE, TOR <br /> CHECK <br /> HECK If BILLING ADDRESSFi i _c � 6etr6c ' p-()O L-4'r-2, <br /> FACIuTYNAME TL i2-+ClK70vOkfoo IF" <br /> Pb(� ard <br /> SITE ADDRESS —F�ACj 85371, <br /> Street Number I Direction Street Nama CI ZI Cade <br /> HOME Or MAILING ADDRESS (If Different from SltelAddress \e Ii.)I f�h r t I_., of <br /> Street Number V� r CShc eret�N-aLme <br /> CITY STATE ZIP qL L3-7 3 <br /> PHONE#1 ET. APN# LAND USE APPLICATION# J <br /> 'tel>'�8 -ZZI-2�1b 235°5-30q <br /> PHONE#2FxT BOS DISTRICT .� LOCATION CODE <br /> (Zdv S' O U 5 C�fD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR . 1e <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME S 4 I /4\ ,f 1� NE# ZZI'"Z110 Ext. <br /> HOME Or MAILING ADZ SSL (nJ FAX# <br /> 1 <br /> CITY �j/yl,� STATE / A ZIPQ 5 <br /> 21 <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 /> 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: [ O"k0 I <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PAR Tv 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 /> t0 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. P <br /> r <br /> TYPE OF SERVICE REQUESTED: T-6C-'C� C-c5 `}"L--L <br /> COMMENTS: /�N F® <br /> �'✓Oq ,6 2Q�� <br /> h E<yI,�RO�fNCO <br /> �TyO pMRNT�N)y <br /> I. <br /> ACCEPTED BY: � � EMPLOYEE DATE: f _ - I t _ ^'T <br /> ASSIGNED TO: A-\ <br /> \\� EMPLOYEE#: DATE: o -II10 LO _ l�/ <br /> Date Service Completed (if already completed): SERVICE CODE: j PIE 1lpt) <br /> Fee Amount: Amount Paid Payment Date '4 A/l <br /> Payment Type 61 Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/117/08 <br /> 1R <br /> L - 2s— k-) <br />