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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> e ___ <br /> SEWCE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> pr730 <br /> LIu7_7 <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> u <br /> SITE``AD''DRESS sy A <br /> v0� Street_.umber Dire tion /—L���_A� .-.treetName ����G- _Cl�rt _ Zip Cod;: <br /> HOME 41'.VIAILING AuORF": (If Different from Site Address) <br /> Street Number =1 Name _ <br /> CITY STATE ZIP <br /> ST, A rev s Inlo- 6��U <br /> PtIMjE#1 EXT. APN# LAND USE Ar ATI N# <br /> ( �) -o <br /> PHONE#2 EXT. BOS DISTRICT LOCATICN CODE <br /> C:ONFRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> =_ ' i CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ext. <br /> �l)e oI1 s`a -S 7 <br /> HOML"or MAILING ADDRESS FAX# <br /> ,.33ao W�C''c <br /> CITY fJ .Ij'Id STATE C,� ZIP EV/ 91 <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 projegr� <br /> ac•.ivity will be billed to me or my business as identified on this form. � �10 <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 JOAAOU0 �0V, <br /> COLNTY Ordinance Codes, Standards,STATE and FEDERAL laws. JqN n D <br /> APPLICANT'S SIGNATURE: / DATE:�� �`-/� SAN _0A ( ?�16 <br /> QU lyr VV/ IV <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT RI f(��, [/IJP�C7t'1ROM�IVTOUN7Y <br /> If APPLICANT is not the BILLING PAR 1TY,proof of authorization to sign is required T Title o�,ARI" �N <br /> AU T HORIZA T 10111 I O RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above T <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time It is provided t0AA or <br /> my representative. /I""�� <br /> TYPE OF SERVICE REQUESTED: r'U1 e119 ��• <br /> COMMENTS: '��v <br /> SAN�O 2416 <br /> yE UJVjq VIN <br /> ACTH oo Aq r Nry <br /> MF�►T <br /> At <br /> ACCLPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: Q 2 EMPLOYEE.#: DATE: <br /> Date Service Completed tif already completed): v L SERVICE CODE: � 1� P 1 ED <br /> Fee Amount: Amount Pa 3 l0,n� Payment Date <br /> Payment Type Invoice# Check# 3 Received By:� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />