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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> AJ(7) <br /> V <br /> ^� � CHECK If BILLING ADDRESS <br /> FACILITY NAME /O -C V v <br /> SITE ADDRESS ' k <br /> l�39 N 'C' Z Jov�a � S-fi� �1- ��,�;� <br /> Street Number Direction Street Name i Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) 1 Qh/ l�- ,{�/� <br /> Street Number U 1 `` c'Street Name <br /> CITY STATE ZIP <br /> c GGC-� C-14— S-20 4� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( 39 S — 0 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> '\J 1 - CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1 PHONE# ExT. 111 ��` <br /> HOME or MAILING ADDRESS FAX# <br /> L CA" L— ( ) <br /> CITY 9 C I/ �0"K <br /> / STATE ZIP Q � ZQ <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 an FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: I I // &L - <br /> PROPERTY/BUSINESS OWNER PERATOR/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 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: rood a PAYMhIq <br /> _ <br /> COMMENTS: <br /> SAN JOAOUIN COUNTY <br /> ENVIROMEN TAL <br /> n HEALTH DEPARTMENT <br /> ACCEPTED BY: �1��� EMPLOYEE#: DATE: II_ <br /> ASSIGNED TO: F--Jo i rlL-c h'l)=- EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: /J� Amount Paid 3 c�'U Payment Date <br /> Payment Type C Invoice# Check# Received By: <br /> ct <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />