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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> J <br /> OWNER/OPERATOR �� <br /> 7 <br /> CHECK if BILLING ADDRESS <br /> 1 <br /> FACILITY NAME 1 <br /> SITE ADDRESS ( I 2 LA , '/�� \/O j,,,, I I�V Q.T <br /> ��/1 b►T GGA <br /> I Street Number Direction W ( StlreetLvNam1e Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) (� 2 L(„(n�A Or <br /> street Number Street Name <br /> CITY F <br /> � � ✓ci f � 1-2��.'l TATE _ IP n � 7-' <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# 1 <br /> ( t 3 - �oCi4�S <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> ` C1 1 "_) CHECK If BILLING ADDRESS <br /> L V,In 1-(— C-) /0- <br /> BUSINESS NAME <br /> J l (t PHONE# EXT. <br /> Co hy' km v lvgl) <br /> HOME or MAILING ADDRESS _ jj FAX# <br /> vi �%`� ��✓ ( ) <br /> CITY C STATE�` ZIP C%7 <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: ��,r DATE: <br /> PROPERTY/BUSINESS OWNER Ell" 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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It Is available and at the Same time It IS provid _me or <br /> my representative. /1YY <br /> 71 <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: Ar0t ? <br /> C�(XiV Jhip ? 19 <br /> HNVj pEpJOAQU/1V co <br /> gR Mf TM <br /> NT <br /> ACCEPTED BY: c EMPLOYEE#: G�Co- DATE: /q <br /> ASSIGNED TO: EMPLOYEE#: r DATE: /_} /q <br /> Date Service Completed (if already completed): SERVICE CODE: F P/E:lo7�2 <br /> Fee Amount: I > <br /> 10 Amount Pa' !S� O Payment Date <br /> Payment Type Invoice# Check# Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> �� t3(lol07 S <br />