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j <br /> SAN JOAQUIN )UNTY ENVIRONMENTAL HEALTI ±,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C� 1.C' <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS <br /> sbw htCtk , U <br /> FACILITY NAME S<}, <br /> SITE ADDRESS <br /> Street Number Direction t"l Street Name 1 C' 1 ZI Cod/ev <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 111(;0G 2-00 Street Number Street Name <br /> CITY STATE ZIP <br /> �UU h c <br /> PHONE#'I xT APN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> YeJQ CHECK if BILLING ADDRESS <br /> BUSINESS NAME X71^ PHONE# EXT. <br /> C�h T h 3 <br /> HOME or MAILING ADDRESS FAX# <br /> 1}- ( 3110 ) <br /> CITY -y-�-' STATE -, ZIP Com. <br /> I ('�M <br /> BILLING ACKNOWLEDGEMENT: 1, 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 <br /> or 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,Standar ,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �6-P Cv DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAG R ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required I True <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 170ci _ le . O'b4--L- PAYMENT <br /> COMMENTS: <br /> MAY 17 2012 <br /> <A,N joAQUrN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPAR7101ENT <br /> ACCEPTED BY: O(-L 0 t 9k EMPLOYEE M DATE: -5 ,' r 2— <br /> ASSIGNED <br /> ASSIGNED TO: /V I -C EMPLOYEE M Ze0 DATE: '5-ft elf-z- <br /> Date <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: 16,01 <br /> Fee Amount: 37s .� Amount Paid — Payment Date C, <br /> Payment Type Invoice# Check# ' U Received By:TF <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />