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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACIUT`�ID# SERVICE REQUEST# <br /> �� FR6a�3�g�� sK 515-7S tfl '1 <br /> OWNER/OPERATOR - <br /> C J C t `+• , ECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Jell sin K� UpesstcY�.�r"av�s;le �-rY�r � 'o - <br /> / s F_ ' e rMre¢t Number Dlrecti¢n Sire¢t Name CI ZI Code <br /> HOME Or MAILING ADDRESS (If afferent from Site Address) <br /> _g earl <br /> Street Number Street Nam¢ <br /> CITY Sa N C SLTJTE ZIP <br /> PHONE#1 En. APN# LAND USE APPLICATION# <br /> PHONE#2 BOS DISTRIY LOCATION CODE <br /> o�U <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORLl ) ' �7)� CHECK If BILLING ADDRESS <br /> BUSINESS NAME - '/ PHONE# EXT. <br /> 06 2%Z <br /> HOME Or MAILING ADDRESS L FAX# <br /> rl / ' ( ) <br /> CITY .� STATEC. _ ZIP - -4. 5- <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 �work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STAT F a RAL laws <br /> APPLICANT'S SIGNATURE: �s DATE: V I l l <br /> PROPERTY/BUSINESS OWNER❑ O TOR AGER Y9 OTHER AUTHORIZED AGENT ❑ _�iec r/7 7/�Y <br /> If APPLICANT IS not the ILLING ry 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. "�BN q� <br /> TYPE OF SERVICE REQUESTED: E�21 L0 Z -40,1`7 CFI V fw.Ud <br /> COMMENTS: �0+� <br /> CGtan9, O'V ot.Jrer NOV 10 1 <br /> EEdjYAOARONNIFNTAL <br /> HEAl7H DEPARTMENT• <br /> ACCEPTED BY: EMPLOYEE#: DATE: /- . / <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O / PIE: 02 <br /> FeeAmount: a/b Amount Paid l h r� Payment Date ( . ' 17 <br /> Payment Type Cwstj Invoice# Check# - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />