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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> I OW <br /> OWNER/OPERATOR <br /> N\A-n �U,F,G o� CHECK if BILLING ADDRESS <br /> FACILITY NAME Aip.VNV '& <br /> SITE ADDRESS <br /> � �'-�{9Z-•��VL�/i1J l>� ���r.•-t� �7�`-�' <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY �f32- �'LC bCSTAT ZIP q 52— <br /> / <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#T go EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR M(A` vxt 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME1 N y,( - r?t/ `�� P J ExT. <br /> J V' 4/� 901 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY L �^ STATE ZIP 0[5--2'J <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 L laws. <br /> APPLICANT'S SIGNATURE: � DATE: V� �/ 1 CA <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER A OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of iuthorization to sign is required <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same tis provided to me or <br /> my representative. �' P <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 44 <br /> CtiVVc 6 n ,n v 1 e O 8 <br /> �/ �oA 1?D19 <br /> FNt, QU�N <br /> ft;tTHOOpqCouly�, <br /> NT <br /> ACCEPTED BY: r+�n�y/,� EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 0-Z'1 eA <br /> of <br /> Date Service Completed (if already completed): SERVICE CODE: f-�!., P 1 E ( Q 21 <br /> Fee Amount: ITP <br /> Amount Paid /'��, Q PaylmJe�ntt Date <br /> Payment Type Invoice# Check# Rece' ed y: -1 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />