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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gose e3N,,o m 'q_ 00 -X'16 <br /> OWNER/OPERATOR c� <br /> CHECK IfBILLING ADDRESS <br /> � <br /> FACILITY IVAME <br /> SITEADDRESS <br /> ^� A\R 5tC�LV-\ly, 5ab l <br /> _Sl 1 Street Number i Direction �\L Street Name. city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �\�tu`N C 2.tn! <br /> ( � �'n<Cy�Y� \ ��4 Street Number Street Nznne <br /> CITY STATE ZIP <br /> S }�`�VQ j-, <br /> cry <br /> PHONE#11 EXT. APN LAND USE APPLICATION# <br /> c a�) LA aov <br /> PHONE#[ EXT. EsOS DISTRICT LOCATION CODE <br /> (2c-)) 4`1 -?troy <br /> OONTP ACTOR/ SER` CE REQUELSTOR <br /> REQUESTOR �1 C�Y\' C,\P'(V\ CHECK ifBILLING ADDRESSL�E1��]f <br /> BUSINESS NAME PHONE# Ex-r. <br /> HOME or MAILING ADDRESS FAX# <br /> �j500 S (areerv,l\e �. L3 1 (Y)15) 9a5, 3'7U a <br /> CITY STATE ZIP 9 •7O4 <br /> )l <br /> BILLING ACKNOWLEDGErtriENT: 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 appli tion and thatthe rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standard TA and FEDE a <br /> /11 <br /> APPLICAN T'S SIGNATURE: sb— DATE: �7 <br /> PROPERTY/BUSINESS OWNER❑ 1 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 to me Or <br /> my representative. `` <br /> TYPE OF SERVICE REQUESTED: V�LC\ � � C_ 1 `c ( IL <br /> COMMENTS: RECO`„D <br /> JUL 12 20i <br /> SAN UO JOAQUIN COUNT) <br /> HEALTH MENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: J - <br /> ASSIGNED T0: IF7c EMPLOYEE#: DATE: <br /> 1 <br /> Date Service Completed (if already completed): SERVICE CODE: 3 PIE: <br /> Fee Amount: 1J�« ` Amount Paid _ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />