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SAN JOAQUIN C_ OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> # <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST(-'h <br /> '�25�'4+�✓an <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS L_I <br /> 6�, Vl <br /> FACILITY NAME bYI��� ��{jT�ss <br /> SITE ADDRESS V 1 IISk�al <br /> 6 3 1 C! Zi Code <br /> St7eet Number Dlrectlan Street Name <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP-' _— <br /> CITY <br /> EXT. APN# LAND USE APPLICATION# <br /> PHONE#1 <br /> (ib1st <br /> ExT BOS DISTRICT LOCATION CODE <br /> pt�aE#2 ! 6 <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR CHECK if$ILLING ADDRESS 0 <br /> &I,k, 4A Z�ah PHONE# EXT. <br /> BUSINESS NAME 7 q- b I <br /> oY�CI� <br /> Fax# <br /> HOME or MAILINGADDRESS n <br /> 20$ <br /> } CITY � STATE ZIP p)( t <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 /> C=4TY Ordinance Codes,Standards, TATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER LJ111' PERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sigh 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it i5 available and at the Same time it is provi�a t0 me Or <br /> my representative. h AfY <br /> TYPE OF SERVICE REQUESTED: Ryd coo l V`I�tb r p� <br /> COMMENTS: <br /> (V&W owyt&r AR <br /> SJ <br /> ejvw <br /> AQ�,14�CVZAJL <br /> ACCEPTED By. /f//) h EMPLOYEE M DATE: �� r <br /> ASSIGNED TO: ! Sa j Ss m V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: LFC 0 U PIE: i <br /> Fee Amount: At Amount Pa i J �� Payment Date n <br /> Payment Type s Invoice# Check# Recei6d By: <br /> EHL)48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br /> J <br />