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SAN JOAQ IU N COUNTY ENVIRONMENTAL HEALTH 115EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# `SERVICE <br /> -7RlEIQUEST# <br /> IV(Nv v F�D� I�I'�z <br /> OWNER f OPERATOR <br /> O(Z M /' ( CyH,,ECK If BILLING ADDRESS�I <br /> FACILITY NAME J` b Iv j V( C C y <br /> I {,71uJ' v <br /> SITE ADDRESS <br /> 10 bR- MfY2ttN reef Ml�2 Ki JtZ SZoGCTDN � SZd. <br /> Street Number Direction Street ame CI Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 22 0 11M) vC— Street Number Street Name <br /> CITY STATE ZIP <br /> S7,L) C/k - ?52-C) <br /> PHONE#t EXr' APN# LAND USE APPLICATION# <br /> 031) 7- 1 -7 5 <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( I <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> S267✓LI. 1 CHECK If BILLING ADORE55 <br /> BUSINESS N E (V tJ PHONE# Ems. <br /> P F 2C �c �rz 2 B <br /> HOME or MAILING ADDRESS FAX# <br /> 3 7 5 Et- PI u A L b R- :ft b ( ---r` <br /> CITY MOGt��A� STATE ZIP SZa <br /> BILLING ACKNOWLEDGEMENT: 1, 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. r 1 <br /> APPLICANT'S SIGNATURE: , _ �� y DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,Proof of authorization to Sign is required Titl¢ <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 assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL WEALTHPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. L"v/ <br /> TYPE OF SERVICE REQUESTED: Z�iIG YIb <br /> COMMENTS' IVEO <br /> SqN APR 5?016 <br /> FM�AQUfiV C <br /> hE gL71 0 f qR O'JNn. <br /> ACCEPTED BY: EMPLOYEE DATE: ' <br /> ASSIGNED TO: EMPLOYEE#: DATE: / <br /> Date Service Completed (if already completed): SERVICE CODE: ���2 P/E: 1 <br /> Fee Amount: l'� -0V Amount Paid-- Payment Date _ <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 <br /> jeCAWf C.aP will I, e-ma;[&01 to <br /> y SR FORM(Golden Rod) <br /> 07/17/08 �� r'w�l L /)e f+- Q/ <br />