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' J NrThr�E -rr- x i° <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Y <br /> 4 F <br /> Type of Business or Property FACILITY ID# SERVICE REQUE/ST# r <br /> OWNER/OPERATOR <br /> ` NIcK, 61o,41%ID,S CHECK If BILLING ADDRESS CI' <br /> FACILITY NAME <br /> SITE ADDRESS F. 0 -IStreet Numberon Street Name Ci ZID Code A` <br /> HOME or MAILING ADDRESS (If Different from Site Address) L <br /> 3cX0 x14A Dom{ ACOS - <br /> Street Number Street Name y <br /> CITY <br /> wD t STATE G4 QIP a{S 2-4•2.' <br /> � S <br /> PHONE#1 ExT APN# LAND USEAPPLICATION <br /> # { <br /> coq } 3� 5s91 osr- z1z, 134geoD, 3 <br /> z <br /> PHONE#27• BOS DISTRICT LOCATION CODE <br /> i <br /> ye <br /> CONTRACTOR I SERVICE REQUESTOR a <br /> REQUESTOR <br /> ("t ice• "�� <br /> SOY CHECK If BILLING ADDRESS r 'µ , 5 <br /> f3US1NESS NAMEPHONE# 3 Exr } Nk a <br /> m <br /> HOME or MAIUNG ADDRESS Z( FAX " $ <br /> r�x eo f I} 3�4- 0-7z3 <br /> s <br /> CITYSTATE <br /> I D ZIP <br /> LOD. C� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent'of <br /> acknowledge that all site and/or project specific.ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project w < <br /> or activity will be billed to me or my business as identified on this form. •' &. <br /> LNS <br /> x <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 JOoAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F ERAL laws. <br /> S a; <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT CI ay <br /> If APPLICANT is not the BILLING PARTY,proof of authorization 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 70AQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as it is available and at the same.tlme It i5 <br /> provided to me or my representative. <br /> ?� <br /> TYPE OF SERVICE REQUESTED: RECEIVE. = <br /> COMMENTS: <br /> DEC 3 2008 ` r <br /> SAN JOAOIIIN 000f1 <br /> Wim^ ENVIRONMENTAL = � � x j <br /> HEAk.T4l DEP.ARTMEN <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ` ASSIGNED TO: MMA/A EMPLOYEE#: �C�1 J DATE: <br /> #r /]ate Service Completed Elf already completed): SERVICE CODE: ✓vs�2L PIE: <br /> / <br /> Fee Amount: w(b Amount Paid p, Payment Date I 3 (P'", <br /> I Payment Type Invoice# Check# S4� Received By: <br /> t EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/1712003 <br />