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SAN JOAQUIITCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST >> <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � � � S _uu-lS-7Sq <br /> DIVINEROP€RAT � 1 - _ CHECK if BILLING ADDRESS® <br /> FACILITY NAME u^y) <br /> i 0(v/ <br /> SITE ADDRESS I�t i !._ S S �A� U U0�IY(J1 oC IC�-`/, G� <br /> Stree[Number Direction Sheet Name City <br /> T <br /> HOM or MAIL G ADDRESS(('''��(If Different from Site Addr:ss) <br /> �J• pC -- St;eet Number Street Name <br /> // CQ TATE ZIP O <br /> N /T <br /> PHONE#1 EXT--T- <br /> APN# LAND USE APPLICATION# <br /> (Soq) � - S-O 1 - — <br /> PHONE#2 EXT. EDS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERN710E REQ UESTOR <br /> REQUESTOR t4 <br /> C) „V U( A OV I< A/kk/ CHECK if BILLING ADDRESS <br /> ED- <br /> BUSINESS NAME PHONE# EXT. <br /> 'Y) 5"'t o I <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITYJ C r/ ^/ STATE ZIP <br /> BILLING ACKN0WLEDGEJiENT. 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. ^� f <br /> APPLICANT'S SIGNATURE: DATE: <br /> —T <br /> PROPERTY/BUSINESS OWNER E3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> • If APPLICANT is not the BILLING PARTY,proof Of authorization fO 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 asp%gjQQ�[1e��nt``inn�formation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 It IS available and at the Same time IS�F.y�q�r�4 me or <br /> my representative. F 7' <br /> TYPE OF SERVICE REQUESTED: 'd U O Sep /(D <br /> COMMENTS: -4)V J0 /U <br /> Ery yg01i/ftr <br /> H THgOE Z&At.ry <br /> 46V r <br /> ACCEPTED BY: G 6ib <br /> EMPLOYEE#: DATE: Ct <br /> ASSIGNED TO: n -�"iA EMPLOYEE#: DATE: t� '69 <br /> Date Service Completed (if already co pleted): SERVICE CODE: �'� ou + PIE U2 <br /> Fee Amount: 13 C' Amount Paid - Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />