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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> _-FA nil 2 5cow �3 1�'-5 <br /> OWNER/OPERATOR (� �/J� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ����,. <br /> �`'� W Street Number Dir tion /"��SrrrsetName L-1 city Zip Code <br /> HOME Or MAILING ADDRESS (If,Different from,I�7�+fie dress) �p n ^ ��; DL <br /> C Nt.�V I �tJ - d '!`S'treetNumber 'v` Street Name <br /> CITY �I ( STATE ZIP L - <br /> PHONE#1 7V/`tet\--fvl EXT. APN# LAND USE APPLICATION# <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 /> HOME or MAILING ADDRESS FAX# <br /> O 3, <br /> CITYD /, L.'0 <br /> STATZIP C j Z <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: KG1 DATE: J �� <br /> PROPERTY/BUSINESS OWNEF,!p_ PeBILLING <br /> TOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <br /> /f APPLICANT is not PARTY,proof of authorization to sign is required Titl <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 Is available and at the same time It Is provided to me Or <br /> my representative. p&MENT <br /> TYPE OF SERVICE REQUESTED: VA CW RECEo ED <br /> COMMENTS: ^1� o MAR ^0�� <br /> v SAN JOAQUIN COUNTYENVIRONMENTAL <br /> HE,g1_TH DEP -NT <br /> ACCEPTED BY: ` EMPLOYEE#: DATE: I �� <br /> ASSIGNED TO: M 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ow P/ 1(� <br /> Fee Amount: Amount Paid `� — Payment ate <br /> Payment Type Invoice# Cts"ck# 1 S Receiveid By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />