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SAN JORIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FL066 SKDD 75-71 � <br /> OWNER/OERAT <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS f_' <br /> L �Zq Street Number Direction C� r V(l•, Street Name J CI (ZI Code <br /> HQ. E r MAILING ADPRESS (If Different from Site—Address) <br /> ItsS ` Street Number �/ SheelYJame <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (ZCR)95E5 J 7 37 J <br /> (HONE'2 EXT. BOS DI�STRI�T` LOCMIO11 tJ CODE <br /> CONTRACTOR/ SERVICE REQUESTOO IR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEP� NE# E T' <br /> C <br /> HOME or MAILING ADDRESS FAX# <br /> IC LIZc ) <br /> CITY STATE ZIP G' <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 laws. <br /> APPLICANT'S SIGNATURE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR//MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,Proof of authorization f0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or <br /> my representative. P <br /> TYPE OF SERVICE REQUESTED: °J Q <br /> COMMENTS: <br /> cia►fie, Cs� a L,Jf� 2r'— son,ode 0� ?018 <br /> U HFAlll , QNINC lI <br /> lifeIX <br /> ACCEPTED BY: EMPLOYEE M DATE: c2- <br /> 7-/Y/('� <br /> ASSIGNED TO: Mi 144 4 EMPLOYEE#: DATE: C9 --1'-� /8 <br /> Date Service Compl d (if already completed): SERVICE CODE: PIE: A!0 o>_ <br /> Fee Amount: Amount Pa' /Sa Payment Date _71/ <br /> Payment Type Invoice# ' Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />