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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST If <br /> �� ui2 No f f� �)/ <br /> OWNER/OPERATOR <br /> Nb <br /> ` � CHECK If BILLING AOORE55 <br /> FACILITY NAME Z>�d�\J r-� 8�6� v , 1�+ ` ,/� (� A 2 <br /> SITE ADDRESS 'l©9 L OI�LJ 15� .. � �/ L l�1`i�1�O _I� Jc� <br /> Street Number Direction Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CINI (� � STA Zip n ZIP q5L <br /> (� <br /> PH0NE#1 EXT' APN# LAND USE APPLICATION# <br /> (Sp a �-�a6o T a ) bl8 <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> 0'7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS O <br /> N <br /> BUSINESS NAME PHONE# Ems' <br /> u ZNc�s su 83� - 260 <br /> HOME or MAILING ADDRESS FAx# <br /> CA <br /> I s Ca R ( ) _ <br /> CITY r--D �q STATE ZIP q 5 ao 6 <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 la /�A �,} f <br /> APPLICANT'S SIGNATURE: �(/f/'' DATE: Io `3 n 1 <br /> PROPERTY/BUSINESS OWNER yq 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, 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 assessmen�j,a7O�/ffprr_oration <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon a5 it IS available and at the Same time If IS prOVl*1 �F�� <br /> my representative. �i <br /> TYPE OF SERVICE REQUESTED: S00d -h D <br /> COMMENTS: 0 Z 1I <br /> E��gOUIAl CO <br /> ri�TH EPgR M 11 <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ 30 <br /> ASSIGNED TO: EMPLOYEE#: DATE: J _J <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# 13 Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 / <br />