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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> A ¢« SERVICE REQUEST <br /> Type of Business orPrope �{C� FACILITY ID# SERVICE REQUEST# <br /> 1I/'IYe, A If Y�SS SKa(07E552-o <br /> OWNER I OPERATOR �^ , CHECK If BILLING ADDRESS <br /> 6S�P t GP 11 <br /> FACILITY NAME / ^/f � r <br /> T I C� ea/ ywe/lr�ss <br /> SITEADDRESS <br /> ®,yr„ G'q <br /> Street Number Olrection r`� St.net Hama `—iJV <br /> HnM: Or MAILING ADDRESS (If Different from Site Address) 5—9 S <br /> Street Number t'rU-'/ ,Street ame LJ <br /> CITY STATE ZI <br /> G <-'T 6149 ?S , 3 a <br /> PHONE#1 EXT. APN# LANC USE APPLICATION# <br /> (ac!)°l 2a9=7-7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> SEYt{'YCL rcc�.QC/iiSTOR —_ <br /> REQU ESTOR CONTRACTOR/ CHECK If BILLING ADDk:SSO <br /> BUSINESS NAME PHONE# Ex'. <br /> 7lx�i�-ethPa u�ll aa9-�� <br /> HOME or MAILING ADDRESS FAX# <br /> CIN STATE ZIP OS/ 3a, <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 IaWS. y� <br /> APPLICANT'S SIGNATURE: � ZGJ� /L , /�DATE: ` ,_-40 [y/ <br /> PROPERTY/BUSINESS OWNER[I PERATOR/MANAGER If OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 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 e;.dironmental/site assessor nt information <br /> [O the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is pr Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: f <br /> COMMENTS: SgN./O 016 <br /> E1VgQrtflN GO <br /> MfgITH p�AR MIlly ry <br /> t <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: rT�e EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): 1w, SERVICE CODE: -- c.,Orol PI E: I�z <br /> Fee Amount: —414 OD Amount Pai� Payment Date !2�) <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 /� <br />