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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0010 't\-) <br /> OWNER/OPERATOR <br /> C��A A/ CHECK If BILLING ADDRESS <br /> CT V 0,4 <br /> FACILITY NAME <br /> SITE ADDRESS L/ H`nC`l�GSIZ <br /> i Code�/ Tm )' 0'7 <br /> HOME or MAILINrG' { <br /> ADDRESS (If Different from Site Address) /J <br /> - qt-15 C-- /\J 727 u I L� / /(�/ treet Number 7 Street Name <br /> CITY STATE zip <br /> cr'2 <br /> PHONE#f ExT. N# LAND USE APPLICATION# <br /> AP <br /> (2- ) � - � �� 3 g 520 t P ^ l 6 o0 o LV <br /> PHONE#2 EXT. BOS DISTRICT ) LOCATION CODE <br /> ( ) l qq <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> JV REQUESTOR <br /> cl-, ` /�^� rr,✓ PZ <br /> /U 'M/ /� (�/Y ' - CHECK If BILLING ADDRESS <br /> BUSINESS NAME J( V /-L n PHONE# EXT. <br /> E1 — -5v ' /G(��L (2'y ) S S1 z <br /> HOME or MAILING ADDRESS FAX# <br /> 111 1 (2"') S `7- <br /> CITY /��2 e $TATE ZIP 11 )7 <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 /> G COUNTY Ordinance Codesda TATE and FED L laws. <br /> O APPLICANT'S SIGNATURE:: `l DATE: 12— <br /> v PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ; <br /> _r 0/ ' 0C <br /> If 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time It Is provided t,Q me or <br /> my representative. N <br /> TYPE OF SERVICE REQUESTED: C I Dy'L o v-�- v 1t <br /> COMMENTS: r�S-fir-( ,-ISS -f—C) <br /> � VJ <br /> q C�y L ,( e�� F� 4�� ,8 <br /> M71V <br /> v <br /> 0-2 "- ;4A <br /> gRT Tq4 1y <br /> MF T <br /> ACCEPTED BY: EMPLOYEE#: I/v , DATE: Z A ` / <br /> ASSIGNED TO: EMPLOYEE#: DATE: r <br /> Date Service Completed (if already completed): SERVICE CODE: U i PIE: <br /> Fee Amount: L Amount Pai !S,-�-bV Payment Date 2 1l <br /> Payment Type Invoice# Ch k# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />