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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICEREQU�E,ST�# <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> �0eCP <br /> FACILITY NAME 1 SS_ / �I,� <br /> WoADDRESI/S vv��GG���� w 2 ( I l�Y-, Ci �G„�� �O C^I qS2 y(D <br /> IFD w ' Ute' ��tree[N�mber Direction 1T Street Name city Zig Cede <br /> HOME Of MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#t EXT APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS❑ <br /> //,, � PHONE# EXT. <br /> BUSINESS NAME ^/I (C. C` <br /> S >✓ (CG7 <br /> HOME Or MAILING�DRE S FAx# <br /> 'l ' ,C G'7 �7e ( ) <br /> CITY STATE <br /> �6p� � I vi- <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 applic n nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE F DE L laws. / <br /> APPLICANT'S SIGNATURE: <br /> : DATE: ©/ ( / <br /> PROPERTY/BUSINESS OWNER acti OPE MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 not the BILLING PARTY,proof of authorization to Sign i5 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 a5 soon as it IS available anp7ll(yMar!%tlf� it is provided to me or <br /> my representative. /'� f�fl�C1ryY 11 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: OCT 2 5 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: �� EMPLOYEE M DATE: 1 <br /> ASSIGNED TO: ' EMPLOYEE DATE. 1 <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: PIE: <br /> Fee Amount: ' J Amount Paid Payment Date t C) <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 5 <br />