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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property ff FACILITY ID# OSERVICE REQUUEST# <br /> IUl11 2tlC <br /> O ER/OPERATOR ` - - CHECK If BILLING ADDRESS Fr <br /> FACILITY NAME f <br /> l <br /> SITE ADDRESS C t. y� <br /> ` (� =et <br /> -� ! <br /> ?'J ��� Street Number Direction 7 5t tName city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE PLICATION# <br /> ( ) /?7430--0rA - o(, o0fZl C4A- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION E <br /> ( ) C <br /> CONTRACTOR it SERVICE REQUESTOR <br /> REQUESTOR - I <br /> N�t � Jl' ,it� JI{✓.� _ 1 Q� _O /IS�OL ��K� CHECK If BILLING ADDRESS <br /> BUSINESS NAME �4 m Y /1 e-c dnt-4w o C I tell) <br /> 36 7 _ 3 7c, ExT. <br /> HOME Or MAILING ADDRESSI FAX# <br /> 10-Z- OJ$YYt0.1 49# ( ) <br /> CITY u>S'. STATE clok Zip 9SZ-�O <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 <br /> or 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./ C <br /> APPLICANT'S SIGNATURE: �'1�---E'_'" ' DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER ALrrHORIZED AGENTG <br /> IfAPPL1CANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,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: U ! cz/ A4 <br /> COMMENTS: JEN&4 I)J f AG -'�.1EP7-1 G S YS <br /> iI" �'Es' s-�-J RECEIVED <br /> APR 0 3 1009 <br /> /6Zn �S�G3 T� 41 /-.G�-70 SAN JOAQUIN COUN <br /> ENVTY <br /> /fi J fiA7i•✓ 5°6�ll�._' IRON_ MENTA <br /> ACCEPTED BY: L l V E t EMPLOYEE#: O 3 �. DATE: r! 3 Q <br /> ASSIGNED TO: S C O EMPLOYEE#: �s DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 5 Z 2 PIE: d12_01 <br /> Fee Amount: �(b v J Amount Paid aQ 0 _ 0-0 Payment Date D <br /> Payment Type Invoice# Check# Recei d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />