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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 goo151 5©3 <br /> OWNER/OPERATOR <br /> En . l� ,tAunP�� CHECK ffBILLING ADORE55O <br /> FAciuTY NAME 1�1�1 e••, r <br /> SITE ADDRESS a-'j �, STp•Tfi ?—o,r,E FHIAl6r'r2aJ 9520 <br /> Stmet Number Direction Street Name CAN Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) ('!G,�. �j.�x Zgel <br /> Street Number Street Nam <br /> CITY rArg-M t AI 11W STATE Ca <br /> ZIP <br /> PHONE#t EcT. APN# LAND USE APPLICATION If <br /> 12bq ) 167-3jo— 07 PA -Ob- VBZ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION DE <br /> I 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK K BILLING ADDRESS <br /> BUSINESS NAME bIL.-L-0r1 ,2 MU404%( PHONE# Exr. <br /> 1 1209 ) 72,34-6613 <br /> HOME or MAILING ADDRESS O aox 2/1 ,o FAX# <br /> P 8WW (Z&q ) 134-077�5i <br /> CITY LAD I <br /> STATE GR ZIP d=�A <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. <br /> APPLICANT'S SIGNATURE: DATE: g- ZJ 07 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHERAUTHORIZEDAGENT❑ <br /> IjAPPL1CANT is not the BILL/NG 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 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: 1 U VC L RECEIVED <br /> COMMENTS: \ p�G 2 2007 <br /> 9A2 - cc .•ca / SAN JOAOUIN COUNTY <br /> � 12y v� 3a--�^^vt ® ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: - - EMPLOYEE#: ( DATE: C <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: S P 1 <br /> ,e Amount: C Amount Paid Q Payment Date <br /> ,ent Type qp• Invoice# Check# \\o 2— Received y: �r <br /> C r *IO• J. <br /> 12-025 ckr SR FORM(Golden Rod) / <br /> )11/1712003 <br />