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SAN JOAQU . COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> I SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -r v wt-' IT � X01�j� �j?V6-7LN ! <br /> OWNER/OPERATOR <br /> TG MMY �O�a 0CHECK If BILLINGADDRESS� <br /> FACILITY NAME G>4S'"-T (�o/.I �(-2,C�j�//�(� co <br /> SITE ADD t�SS� I•-4� -SL�m JGr4 Q u I� S T^ <br /> C4 Street Number I Direction I Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from�S/ite Address) <br /> f y � sG/ <br /> QQvE� /� i•'V�� Street Number Street Name d <br /> CITY STATE ZIP <br /> i_G17 I C-4 Z <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> JG,�� C7dy f� CHECK if BILLING ADDRESS <br /> I <br /> BUSINESS NAME —i�1ii i ( S' PHONE# EXT. <br /> HOME or MAILING ADDRESS ' FAX# <br /> CITY AGK �( STATE C A ZIP cY Saa;' <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 /> also certify that I have prepared this appli a' and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> ( <br /> COUNTY Ordinance�.OueS, . Zai7uai uS,STA' an FEDERAL laws. <br /> APPLICANT'S SLr'.I:ATURE � 5 1( 7 /2eo 1 <br /> DATE ff . A " <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ THEIR AUTHORIZED AGENT I'-0OJ CCr`v 1 A"J C� � <br /> If APPLICANT IS not the BILLING PARTY,proof of author tion 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 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. 1 <br /> TYPE OF SERVICE REQUESTED: F '>08 RECEIVED <br /> COMMENTS: <br /> M/;,� 1 ,7 L u'.� <br /> 2tr� Dv)Ye� SAN JOAQUINCOUNTY <br /> ENVIROMENTAL <br /> }IEALTH DEPARTMENT <br /> ACCEPTED BY:(F-:�Qa EMPLOYEE#: DATE: <br /> ASSIGNFD TO: L� l EMPLOYEE#: DATE: <br /> Cate Service Completed (if already completed): SERVIC. CODE: P/E: I <br /> Fee Amount: 4� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />