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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE UEST# <br /> ��5� <br /> OWNER/OPERATOR �-' <br /> \`s" A (__, rA CHECK If BILLING ADDRESS 0 <br /> FACILIT NAME <br /> SITEADDP.FSS ' 3�y ��/V� Sul ' S C�L <br /> T- <br /> Street Number Direction _ St.eet Name Zi Code i <br /> HOME Or MAILING ADDRESS /If Different from Site Address) <br /> Soyu INg I CI Street Number Street Name <br /> CITY STATE n ZIP <! <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (� t,CV 'Ag - SSG _ <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^ <br /> M y///���-� , 1 �� �t � F t� `1t C,,ECK If BILLING ADDRESS4.J <br /> BUSINESS NAME I 111 1 r PHONE# EXT <br /> J�w SGkAw 1iQL� )J 9� - � STC <br /> HOME Or MAILING ADDRESS FAX# <br /> S-6c, 6- S 4 N, �-- RO () <-b '(31- 3 5 y <br /> CITY C'�� / STATE C ZIP C1 S <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 JOAQLJIN <br /> COUNTY Ordinance Codes, Standards ST iirrz and FEDERAL I <br /> APPLICANT'S SIGNATURE: DATE: �� ` " k3i 6 <br /> PROPERTY/BUSINESS OWNER OPERATO ANAGER ❑ OTHER AUTHORIZED AGENT 0 <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tirte <br /> AUTHO,tI .ATION TJ RELEASE INFORMATION: When applicable, I, the owner or operator c, the property located at the above <br /> site address hereby authc,;ze the release of any and all results; geotechnical data and/o, environments bite asses;mert information <br /> '0 the - .lOAQUIN CowlTY ENVIRONMENTAL HEALTH DEPARTMENT os sciii as It IS available ani at i11,F time it is F-ovic:ed to me or <br /> ly represc"n• tive. <br /> TYPE OF SERVIC EQUES7 ED: d <br /> E -EWE fir-►,,,e) u,l f�P,�J l vl f Sc�,lo 1 �d1 <br /> l\n�Y 1 2 z <br /> o1b ' U <br /> SAN,y,)AUUIN COUNTY <br /> NVIROMENTAL <br /> H A4`i 6 Y: —�- -----'EMPLOYEE#: DATE: I r <br /> ASSIGNED TO: V V EMPLOYEE#: DATE: �Zlj <br /> Dat, Service Compia':cd (if alta-uv cc m:)!2ted): --�— SERVICE COD.: 1 E: <br /> Fee Amount: Amount Paid <� j Payment nate <br /> J <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> k54142z. <br />