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SAN JOAQUIN .OUNTY ENVIRONMENTAL HEALTH DL- .RTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />rdER / OPERATOP <br />FACILITY ID # SERVICE REQUEST # <br />PHONE# EXT. <br />t -� L4 -0 <br />@SFr <br />CHECK if BILLING ADDRESSi.�,! <br />FACILITY NIAME <br />— --- - -- <br />SITE ADDRESS 1 �l yv� �, <br />_ Street'Jumber Direction _ _ Iy S!rcet Name f �C_ <br />.�__.. .�.......�.._...y..—.._! �. 1—�...!pCode <br />HOME Or iMAILING ADDRESS (If Different from Site Address) <br />Strec_t Numhcr 1----j.-'reetfianie <br />CITY STATE ZIP <br />PHONE #1 <br />riIONE #2 <br />EXT. APN #T / L%ND USE APPLICATION # <br />EXT. BOS OIST ICT LOCATION CODE <br />��- <br />CONTRACTOR / SERVICE REOUFS FOR <br />I'REQUESTOR <br />1 �C /' \c �t� CHECK if BILLING ADDRESS <br />L— <br />BUSINESS NAME <br />" <br />PHONE# EXT. <br />t -� L4 -0 <br />HOME or MAILING ADDRESS <br />FAX# <br />CITY _ \ U STATE / / ZIP C) <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 lica P'q and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNT)' Ordinance Codes, Standard STA E n FEDERAL laws. <br />AIPPLICANT'S SIGN" URE: <br />DATE:_ <br />_ <br />PROPERTY I BUSINESS OWNER ❑ OP RA OR MANAGER ❑ OTHER AUTHORIZED AGENT r l� <br />If APPLICANT IS not the BILLING PA qTv, proof of authorization to sign is required Titre <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 t0 me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: L1 S -7— <br />COMMENTS: <br />AdCCECTED BY�� <br />ASSIGNED TO: n rA// Z ,�\ <br />` <br />Date :;en ,.; .'o"mlpleted(if Jalready completed): <br />Fee Amount:�U Amount Pa <br />Payment Type Invoice # <br />EHD 48-02-025 <br />07/17/08 <br />EMPLOY'°E #: <br />EMPLOYEE #' <br />SERVICE COD' --/ C <br />—�Paymeni Date <br />Check # G 71 d <br />14A 2 6 ?Olf <br />SqN u()gG?UirJ OO <br />H� �rH DOM�N7qlN <br />DATE: f/, 7— <br />DATE: `j Z <br />P I E:.1 )e' <br />rz, /, r- <br />?ceived By: <br />SR FORM (Golden Rod) <br />