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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> �v`,1 1, 5p\ <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ��W V \ n �J-C~\/� _I I C/�\ t--T7 n <br /> - _n _ _ <br /> SITE ADDRESS —1 /it 1 Z c� `J' F�S-ito <br /> Street Numbr Direction Street Name Ci Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) `''�; l-2-0,:; <br /> Street Number 1 , V`Street Name <br /> CITY ^. STATE ZIP <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# V <br /> 11M) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 1i S `7 ; <br /> I< CHECK if BILLING ADDRESSIZ <br /> 7-7 <br /> BUSINESS NAME (� C\/, 1 IV 1 �JPHONE# r�1 Q EXT. <br /> 1 "I O — ��d� <br /> HOME or MAILING ADDRESS FAX# <br /> yzo� C� ( ) <br /> CITY STATE ZIP SZ�� <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: -x J�,i� �7 DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> I{APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tirle <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 /> TYPE OF SERVICES REQUESTED: l� C <br /> COMMENTS: 4AR O <br /> C <br /> N�N►�ri0 p�HFN�Nry <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 V G���� t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: JL002 <br /> Fee Amount: eJ Z Amount Pai /6-2, v Payment Date <br /> Payment Type Invoice# Check# Received B <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />