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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> pe of Business or Property FACILITY ID# SERVICE REQUEST# <br /> W <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> G <br /> SITE ADDRESS 1 `'gymu, <br /> ',� /i G�L <br /> SUeet Num er DlrecHon vv r r(/VSllreet Na a �t—'I V LC CI I�� ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY ^- STATfl_-- ZIP <br /> PHONE#f ExT' APN# LAND USE APPLICATION# <br /> PHONE#2 En, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME HONE# ExT' <br /> HOME or MAILING ADDRESS u FAx# <br /> ( I <br /> CITY STATE ZIP <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,ST and F D RAL laws. !/ <br /> ➢CAPPLICANT'S SIGNATURE: DATE: dI i !i0(} <br /> '/7 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MA GER ❑ OTHE AUTHORIZED AGENT ❑ <br /> IfAPPLICANTis. a BILLING PARTY Proof OfaUt r/zatlo to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 ass ment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it Ff to me or <br /> my representative. - t� A; A <br /> TYPE OF SERVICE REQUESTED: 00Co-, 11-6� `l <br /> COMMENTS: S,gNdV /I <br /> Gla <br /> ENV QU/N U/ <br /> / HE9GTy�EPq�cot) 7y <br /> ACCEPTEDBY: 0,e4tjEMPLOYEE#: DATE: I -20- 17 <br /> ASSIGNED TO: Tej EMPLOYEE DATE: <br /> 1 <br /> 1 <br /> ,�L(3-17 <br /> Date Service Completed (if a(eady com eted): SERVICE CODE: O PIE: �C! <br /> Fee Amount: r-, o Amount Pal /S� U� Payment Date Z , <br /> �. <br /> Payment Type V ,- Invoice# C ck# �'7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />