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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ct)ma S/Zo07�43 <br /> OWNE /OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 'v✓e� '/ <br /> SITE ADDRESS _7?); 1 (�I I��y�O� [�v� 9ti �j/ZP6, <br /> Street Number Dire¢tlon �I Stre^et`Name �I Cfi-J(/ JZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY �,_ _---._—__ STATE ZIP <br /> PHONE#1 EZT. APN# LAND USE APPLICATION# <br /> q09 93I- 735-g <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> (ao3> 9f X206 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 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 /> >(APPLICANT'S <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> 7wPPLICANT'S SIGNATURE: DATE: <br /> 11Z2 9/7 <br /> PROPERTY I BUSINESS OWNER 11 OPERAT ANAGER ❑ ER AUTHORIZED AGENT 91 £C,Cfff>/ON C64D1,147an' <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 It Is provided to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ^�. l.i.%V1 LA <br /> COMMENTS: <br /> SAN JOAQUJIV COU <br /> HFq TH MRRMrAt <br /> ACCEPTED BY: NCAA Com\\ EMPLOYEE#: DATE: <br /> ASSIGNEDTO: WJ✓, , EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O&1 PIE: 16(9'2_ <br /> Fee Amount: 5� I`jy:; Amount Paid '` f�� (� Payment Date <br /> / <br /> Payment Type - _ Invoice# Ch k# Rec Ived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />