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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S - cw 14-61 70'A/W <br /> OWNER I OPERATQ_ <br /> CHECK If BILLING ADDRESS <br /> Y1 M r <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name Ci Zio Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) plglok�1 �� U C, <br /> Street Number 1 Street Name <br /> CITY �< � TATE r A ZIP <br /> PHONE#1 _ EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT --7LOCATION CODE <br /> ( ) C,>(:)7.._ 01 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEVVV PHONE# _ EXT. <br /> HOME or MAILING ADDRESS / ` r (Ax# ) <br /> CITY CA TATE�. SZIP <br /> rte, 9-,45;-) 1-2- , <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 /> 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 /> r + <br /> APPLICANT'S SIGNATURE: S �I,wllr ,,, ^A Zp �L DATE: <br /> PROPERTY/BUSINESS OWNER* OPERATOR/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 provi0 iV Or <br /> my representative. A�/fENT <br /> TYPE OF SERVICE REQUESTED: L C,�L,l, zi u." <br /> Aipw <br /> COMMENTS: iyvv Z 14 <br /> SA ENV fl MC CoNrr <br /> FIEALTH f EEPANr <br /> NT <br /> ACCEPTED BY: , EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: G PIE: <br /> Fee Amount: ,3 — Amount Pai 13d p� Payment Date 1 -71)4- l� <br /> Payment Type Invoice# Check# Q� l 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />