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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 i/•� �,� r J 05 1 J PR Mq j H') i i 1 L CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME i j <br /> � r J_JF !1 1� <br /> SITE ADDRESS I/ � b- lJ wl s^ <br /> S-7 o G J<-i o i,1 2-•1 O <br /> :3U;+ !e?) StreetNumber Direction Street Name C ity Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT- BOS DISTFjjq r� LOCATI N CODE <br /> 11{ ) (J o � <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> !l 7 I <br /> REQUESTOR IRU-VN-L-(; as ���7'a 04 <br /> 0 I !7 ft 1 i L., CHECK if BILLING ADDRESS13/- <br /> BUSINESS NAME`+ ( � � �i l� 1� PHONE# ExT' <br /> HOME or MAILING ADDRESS b 2 2 , } (}/� f�s { "he— FAX# <br /> CITY -S� T 0 G ���� �' STATE C ZIP 9 5 2–/ a <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: ] � a, ? Y DATE: I <br /> PR�RTY I BUSINESS OWNER® OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT is not the BILLING G P.aR7_Y 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 environmentallsite assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon a5 It is available and at the same time.itjAprWl ed to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: -D�CL1� C�`L('C-� <br /> PMMENT <br /> COMMENTS: RECEIVED <br /> • SAN JOAQUIN COUNTY <br /> F-WRANMENTAL <br /> FEB Z 201 !EALTH DEPAITrM ENT; <br /> SAN JOAQUIN COUNTY <br /> ACCEPTED BY: �Ia EMPLOYE& ALTH DEPARTMENT DATE: , V <br /> ASSIGNED TO: ra h a ' at EMPLOYEE#: DATE: � - <br /> /Oa <br /> J <br /> Date Service Completed (if a ready completed): SERVICE CODE: �3 <br /> Fee Amount: 1j(OCJL' Amount Paid Y l Payment Date <br /> Payment Type C C invoice# Check# -3 3c4 Received By: 7r-5�' <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />