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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Pal05RU <br /> OWNER/OPERATOR ❑ <br /> CHECK If BILLING ADD <br /> �Ll L 1 R inti', GLS /�7r2• C�42 � <br /> FACILITY NAME <br /> Pa 1V s1sjL L1 <br /> SIFEADDRESS I.7�¢7 DR4oN 15ZAA h RW�6 F <br /> -F, 5racr«r`r <br /> Street Number Dire <br /> cElon Street Name city ode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number I Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLI ATION# <br /> 61 <br /> ( _ - 7a - ate <br /> PHONE#2 EXT. BOS DISTRICT <br /> LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> DON <br /> 4 r CHECK if AtLuNG ADDRESS <br /> BUSINESS NAME +V PHONE# EXT. <br /> �X 1 <br /> HOME Or MAILING ADDRESS FAX# <br /> • ZO X ( ) - <br /> CITY R $TATE ZIP -573 <br /> BILLING ACKNOWLEDGEMENT. I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this app ' ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards; SE and F2 laws. <br /> APPLICANT'S SIGNATURE: &V4DATE: <br /> PROPERTY/$USINESS OWNER❑ OFERATOR/11iANAGER ❑ DTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY goof of a horiZatian to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: p /� N/TIZATa LDS D/N D/L Ga!/TA13/G 17 �VJ <br /> COMMENTS: AA16 .4Ie?vtb t,/A5•rF ?1-AA/ e-eic <br /> RECEIVED <br /> If7 ! 1op FEB 17 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL. <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P1 E% f- <br /> Fee Amount: ��� C' Amount Paid 5 2 S _ Payment Date 2 �] <br /> Payment Type ✓ Invoice# Check# 3 6 b Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 1,1117/2003 <br />