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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILI 7, mr <br /> Z�')W h-A 0' 5 —P � Zy El� <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRES5O <br /> FACILITY NAME ,•[ �I 6 � <br /> SITE ADDRESSCI 5j�(G>ipJY �5�� <br /> 19,32-1 Street Number I Direction �"_ - 'Street Name il-ty Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY d� C TE ZIP <br /> PHONE#'I y I Exr• APN# LAND USE APPLICATION# <br /> (�ze 2 .l Jan <br /> PHONE#2 Exr, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r <br /> r CHECK If BILLING ADDRESS <br /> BUSINESS NAME fA�]c+ 0/11 1�r t`d i,�11 (&56PHONE2�/113 Exr. <br /> a HOME or MAILING ADDRESS (�L•' ] Y V 1 7 FAX# 5 <br /> CITY dCy'3'� r.` `� G[f(a STATE ZIP 5; - e86 <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 /> r 1 also certify that I have prepared this application and at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FE R laws. <br /> APPLICANT'S SIGNATURE: �'L'" rL DATE: <br /> {� <br /> PROPERTY/BUSINESS OWNER© OPERATOR I 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, 1, 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 i5 available and at the same time it Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: 11`YfRECOVED <br /> h COMMENTS: <br /> 4 5Yv, A'6--/ AUG 2 5 201 <br /> 3 5vb �.►-"y T d}'Q Ca X`1 q Lcbh �/ 1/� SAN JOAQUIN COUt TY� <br /> ENVIRQNMFNTA <br /> HEALTH PEPARTM T� <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: ! EMPLOYEE#: DATE: a�J' <br /> Date Service Completed (ifarreaaycompleted): SERVICE CODE: PIE: <br />' Fee Amount: Amount Paid L�S(p , Payment Date <br /> Payment Type Invoice# Check# 11,+0�7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />