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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST/ <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ra' , <br /> ' Seo <br /> OWNER 10PERAT0�R7� �n `1 ^, — n_ \ /yam CHECK If BILLING ADDRESS <br /> FACILITY NAME 'CA, (t/L &1\.': A""261 Cvl!aYl.k <br /> SITE AADDDRGES$--� <br /> O ✓✓\/ Street Number Ilredlon avast ame CI lZ-i'CGo/tle✓ <br /> HOME Or MAILING ADDRESS (If DIff}re0t m ite Address) <br /> ,�7✓1`VLC•�1 �J Street Number Street Name <br /> CITY <br /> PHONE# ExT' APN# LAND USE APPLICATION`S#L <br /> LA <br /> P _ fr O BOS DISTRICT LOCATION CODE <br /> ( l/` Ili!/ �, `-� U//�� <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR (CHECK If BILLING ADDRESS Er <br /> BUSINESS NAh1F. /1`W C•-e -V J `��LO . CCt`-eS <br /> HOME or MAILING ADDRESS l/ /`tV\(/ FAX# <br /> \ V T,�E ZIP <br /> CITY 01 s' K . <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized lagent�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 /> 1 also certify that I have prepared this application and that the work to be performed 'L one in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA E and FEDERAL Is <br /> APPLICANT'S SIGNATURE AT <br /> 2 <br /> PROPERTY/BUSINESS 0WNERd OPE R/MANAGER ❑ OTHERAUTHO ❑ <br /> If APPLICANT is not the BILLI GPA Y proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORM A • When applicable, 1, 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 COUNT' ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It Is provide o me or <br /> my representative. `!"51 <br /> TYPE OF SERVICE REQUESTED: � *"� <br /> COMMENTS: 1_t,. F4 <br /> �J1X�4.I'�I Q(`• SgN✓' E J, �® <br /> H FNS/R QU/N <br /> �<ry�FpgRr q<N <br /> MF <br /> ACCEPTED BY: o� Q EMPLOYEE#: DATE: n2 12 IQ <br /> ASSIGNED TO: w EMPLOYEE#: DATE: L 113 I <br /> Date Service Comp] ed (if already completed): SERVICE CODE: PIE: I LIZ U L <br /> Fee Amount: Amount Pa -/ i�j�,�� Payment Date 13 <br /> 17L <br /> Payment Type Invoice# Check# Recei✓ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />