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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> i Type of Business or Property. FACILITY ID# rSEI CE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME ('`5, I , <br /> SITE ADDRESS 7 2 <br /> Str t Number Direction Zle)C4 F/ � 15:-zi:p:Ctod-e' <br /> HOME Or MAILING ADDRESS (If Different from Site. ddress) <br /> a4 Street Number et Name <br /> CITY STATE <br /> PHONE#1 EXT. APN# LAND USE A P P I ICATIO <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> /e c 6 v <br /> HOME Or MAILING AD RISS, /'��� G ^ FAX# <br /> CCS � /•f_ �V ( ) <br /> CITY Pis 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FEDE laws. / <br /> APPLICANT'S SIGNATURE: -e— DATE: r �i <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR i MANAGER ❑ OTHER AUTHORIZED AGENT <br /> It APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required T;11e�3�!ly��yy...s ,�, <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property loca p"W <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess i <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It Is provided to me Or <br /> my representative. JAN 1 9, 1 <br /> TYPE OF SERVICE REQUESTED: L S <br /> COMMENTS: N i <br /> ifv� rT <br /> �ac �p vu ld't✓16�s - 1ts h r Sc-ltzj 'A �dV`L"C( <br /> ACCEPTED BY: ��/ EMPLOYEE#: f J n—�/l DATE: j ] 19 <br /> ASSIGNED TO: EMPLOYEE#: C✓� DATE: 1 t <br /> Date Service Completed (if adeady completed): SERVICE CODE: IZ) 6 P/E: J-ZvZ <br /> Fee Amount: / Amount Paid rJ.2 D U 'I 33 Payment Date ! ( 1 1 <br /> 4 <br /> Payment Type Invoice# Check# 1Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> I <br /> i <br /> I <br />