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I. <br /> CC <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7 NT C�e' 0 0-%D �q (- <br /> OWNER/OPERATOR <br /> C ` t CHECK If BILLING ADDRESS <br /> FACILITY NAME r 1 Yv L v L--,C� ' <br /> SITE ADDRESS I CI'� QV �pG Kr"D /✓ G� S O 7 <br /> t:-3 o S Street Number Direction / Street ANameu$ CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) -30 N tzNt2 y � �, I�Lv� <br /> 1 -73 o H�/V- L !v Iry Street Number Street Name <br /> CITY STATE ZIP "l C <br /> �C <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> (,,66'o 3,�& - 6S--2JSal <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> qac - 7�3C-1� 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �c> k1-0- DATE: — <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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, 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 time its Qy led t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 0 <br /> 10 ogQ�i 5 ?419 <br /> y�CTyoEpgRNTUNY <br /> '�NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: v ` � SG iA EMPLOYEE#: DATE: <br /> Date Service Completed (if`already Completed): SERVICE CODE: (\l:1` PIE: <br /> Fee Amount: Amount Paid?IS07, Payment Date <br /> Payment Type Invoice# Check# �70 Recelve By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />