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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/OPPERATOR <br /> ! C/ o `% CHECK If BILLING ADDRESS <br /> FACILITY NAME [/_,(��C/�� <br /> SITE A//DDRESS Ives, Le " <br /> 3(.C� Street Number Direction ,C�U� 7fStreet Name Ci Zip Cade <br /> HOME or MAILING ADDRESS/(If Different from Site Address) � <br /> w• Street Number 3 v/ Street Name <br /> CITYZ—O& ' STA/T(W ZIP <br /> PHONE#1 EXT. APN# LAND <br /> �`�/USE APPLICATION# ✓C <br /> 331K-0636 &d ci Z 50t—D 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> /CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR `� / /J'.,r( CHECK if BILLING ADDRESS <br /> BUSINESS NAME CJ EXT. <br /> C, PIS <br /> HOME or MAILING ADDRESS GL� /j_ i�y Z FAX# <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 thal the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ST andyF�EDE la �f <br /> APPLICANT'S SIGNATURE:/- DATE: / /U <br /> PROPERTY/BUSINESS OWNER 2S OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required 7';rlr <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 me or <br /> my representative. /� <br /> TYPE OF SERVICE REQUESTED: l'gAj t21V' a( �P/j?(l"/ 1[01:-'ecJ- <br /> COMMENTS: J UN <br /> "'.J <br /> O <br /> y ?018 <br /> NP-qizyop'q."/q�N� <br /> RT,yFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid v� Payment Date <br /> Payment Type ,1 Invoice# Check# aDS9/ Received By: <br /> i-_ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />