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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dom. ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 0t>tt /QPE TOR <br /> �,^L ` ^� -� CHECK If BILLING ADDRESS <br /> FACILITY NAME` gyp '1� � \ <br /> SITE ADDRESS 1 <br /> tree N ber Direction rot G,. Zig Code <br /> HOME or MAILING AD4RESS (If Different from Site Address) <br /> SStreet Number Street Name <br /> CI STAT ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> Fid 5n -7-(JS-0!8 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 73 <br /> CON RAS CrOR SERVICE R1EQ STOR - - <br /> REQUESTO CHECK If BILLING ADDRESS <br /> BUSINESS Nr <br /> I PHzO`NOE# (�_ q ,y I T, <br /> HOME or MAILING DDR SS FAX# <br /> CITY ,n STATE ZIP <br /> BILLING A,CKNOWLEDGEFOENT: 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. C� ` <br /> APPLICANT'S SIGNATURE: t` i)t_> `�,17�' ffko DATE: \ � <br /> PROPERTY I BUSINESS OWNER ElOPERATOR/MANAGER [IOTHER 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 I vided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: SAN <br /> EN�gOUIN /U <br /> HEALTH D�qR �iy�, <br /> NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: r <br /> ASSIGNED TO: ha J�f EMPLOYEE#: DATE: <br /> Date Service Completed (if already'completed): SERVICE CODE: s��I PIE: (�8Z <br /> Fee Amount, 1 C>D Amount Pa ', 2:> Payment Date 7/0 <br /> Payment Type DK Invoice# Check# D—Q2�20341 Received By: <br /> EHD 48-02-025 �� SR FORM(Golden Rod) <br /> 07/17/08 <br />