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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 /> OWNER OPERATOR"_,_,,) <br /> p <br /> ' �L{Q l_ CHECK If BILLING ADDRESS <br /> FACILITY NAME _ <br /> i SITA�/D7rDR S (/� �/�/� �t'ul <br /> / r �oeet NiTrttt l �r c�dont nC— Street Name aC Zip Code <br /> HOME Or MAILIN )DRESS (If Different fro Site Address) 1 _ <br /> - i - 6 ` oi, q Street Number Street Name <br /> CITY moi_ STATE Zip <br /> PHONE#1 EXT* APN# LAND USE APPLICATION# <br /> ---7Pu ;Z Exi. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME �c2 M r, _c PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ^�� i <br /> L 1 r� J n ( ) <br /> CITYi 1/ L,.Y-\ /�Qr 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �j r�� � DATE: <br /> PROPERTY/BUSINESS OWNER❑ 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 /> to 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. w{, <br /> TYPE OF SERVICE REQUESTED: n, ^1l <br /> COMMENTS: txc:c�i1 <br /> FEB 05 <br /> 8AN 019 <br /> ENV/RSNV/NC?OUN <br /> H�CTH p MENTA TY <br /> ACCEPTED BY: oulro EMPLOYEE#: 67 <br /> DATE: <br /> ASSIGNED TOC c EMPLOYEE#: DATE: <br /> Date Service C Ompleted (if already completed): J SERVICE CODE: r P/E: <br /> Fee Amount: 00 Amount Paid 11572- _ Payment Date 2 j 5 I/ 9 <br /> Payment Type Invoice# Check# Received By: <br /> C'�-n� 14 �7Lf 2-) �� 1 <br /> EHD 48-02-025 `/� SR FORM(Golden Rod) <br /> 07/17/08 (Jt// O 1N �ll W Is <br />