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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property },FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> � ,/ CHECK If BILLING ADDRESS <br /> FACILITY NAME A. / <br /> SITE ADDRESS _ j 7/�L <br /> Street Number 6`1tion . heel NbIW! 5f b I 6dPIki <br /> HOME Dr MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT" APN# LAND USE APPLICATION# <br /> t (Z0j) J 5-vO PHONE#2 l EXT SOS DISTRICT LOCATION CODE <br /> ( . -III, ( Cc(l <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR O�1 <br /> CHECK If BILLING ADDRESSIJ <br /> BUSIN SN PHONE# EXT. <br /> � 4A lgf�- b <br /> HOME Or MAILING ADDRFS i 1 C (A%# ) <br /> CITY , TATE ZIP r <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigr:ed 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 /> adlily will be. billed to me or my business as identified on this form. <br /> I al -ertif• Mat I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> -uw .yinanoe Codes,Standards, STATE and FEDERAL laws. ; <br /> APPLICANT'S SIGNATURE: 16-0-\ C_.01 DATE: T C <br /> PROPERTY I BUSINESS OWNER 1:1 OPERATOR 1i MANAGER ❑ OTHER AUTHORIZED AGENT ❑ •� <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> . JTHC'RIZATION 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 /> L .yP': .iPll JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided t0 me Or <br /> n j representative. <br /> r--- <br /> TYPEOFSERVICE REQUESTED: �� �>WI-�G(�"jT�/1 PAYMENT <br /> COMMr as: RECEIVED <br /> OCT 07 '1015 <br /> SAN JOAQUIN COUNTY <br /> _ ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> t ACCEPTED BY: EMPLOYEE#: DATE: IO I�j <br /> ASSIGNED TO: ' O.. ,_ f.�l,l I EMPLOYEE DATE: lb.ter IS <br /> Date Service Completed/(if 1re,dy Completed): SERVICE CODE: �( L6� PIE:! (� <br /> Fee Amount: �a.dZIAmount Paid I C9d Payment Date I S <br /> PaymentTypeGt— Invoice# Check# G07 Received By.'/./ <br /> EHD 48-02.025 SR FORM(Golden Rod) <br /> 07/17/08 <br />