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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �O/YrME2C/ffL 77 to�f <br /> OWNER/OPERATOR <br /> � 14 �Q . CHECK If BILLING ADDRESS <br /> J0 P <br /> FACILITY NAME <br /> �21P'41VBE,�2ter <br /> SITE ADDRESS 777 f W �/ 7� STKEET 7_2ACI <br /> 9S3a4 <br /> Street Number Direction Street Name ZI Code <br /> HOME <br /> //o/rrMAILING ADDDRRESS (If Different from Site Address) T2E�su2E /SLAND <br /> e /^14 AV E- O N t0A LM 1 T -7 Street Number Street Name <br /> CITY STATE ZIP <br /> F,¢ NGISCO cA 3 <br /> PHONE 11 EXT. APN# LAND USE APPLICATION# <br /> `+P 40- I5-5- aSo- loo-// PA - /600/0o <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> r CHECK It BILLING ADDRESS� <br /> BUSINESS NAME /t H f L, .t 6 ry L PHONE 01 —/6 r EXT. <br /> HOME or MAILING ADDRESS FAX# J <br /> Vo PO 668-ZS9P <br /> CINTU jZ L0 STATEI,-�A ZAP q� Q/ <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 preparedthis ap ijcation and t t the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,ST E and FED ws. / <br /> APPLICANT'S SIGNATURE: DATE:,_f�f / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/AANAGEROTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of thorization 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 t0 me Or <br /> my representative. <br /> TYPE OF SERVIEE' D/L SG/1"11 /L/T ruD !E >:C 1/lE(fI <br /> COMMENTS: <br /> jUN 0 5 2097 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> FIFA!TH D-'ARTMENT <br /> ACCEPTED BY: OLC U,�l1^ /L EMPLOYEE#: SiG�F'�000Lc'� DATE: <br /> ASSIGNED TO:I� /c)P()u EMPLOYEE#:7 5 �i�xtS' DATE. <br /> Date Service Completed (if already completed): SERVICE CODE: SZ7 PIE: <br /> Fee Amount:.4 S 5 C, t'Zi Amount Paid �� UD Payment Date � 7 <br /> Payment Type C1 Invoice# Check# 3cf/f Received By: <br /> EHD 48-02-021 SR FORM(Golden Rod) <br /> 07/17/08 <br />