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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> i SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR <br /> f L-� CHECK if BILLING ADDRESS <br /> L ❑ <br /> FACILITY NAME r <br /> �aWti L-G��t� <br /> 51TEA MA, ,�. _ ; :S J, Sri' _r T._ I'fo ,^'cam'^ �(�•� s� X539 <br /> Street NumberDirection Street Name - cipi Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ,-5 f�Q <br /> Street Number Street Name <br /> CITY j STAT€ ZIP <br /> PHONE#1 Exr. APN O LAND USE APPLICATION# �1���7, <br /> f9ZS 1 Sers - G?�7 2v4- 05�� fU 6 <br /> PHONE 92 EXT. 0=-3 BOS DISTRJCTLOCATION CODE <br /> (4251 215 3?G-7 6- <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQU ESTOR CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME � PHONE# ExT. <br /> 51�.�. ate.,-�F.a.. �,o�.•s� �.LC� ��5 Sia ��7�7 <br /> HOME or MAILING ADDRESS FAx# <br /> ,.ZS o S� Cay '4r:✓� (97-5 ) 'ZIP ZZ(,G <br /> CITY STATE Zip <br /> �V G/'W—ri J t 1 <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 1 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 /> AP.PLICANT'S SIGNATURE: _�/�j(/ �. _ DATE: let'j <br /> PROPERTY I BUSINESS OWNERO OPERATOR/MANAGER O OTHER AUTHORIZED AGENT <br /> IfAPPLICANT is not the BILLING PARTY.proof of authorization to sign is required I Titte <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 /> i[ provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> ' // c (F I [ I PAYMENT <br /> p � RECEIVED <br /> z4t <br /> -- <br /> JUL 19 2011 <br /> SAN.1CAQt1iN COl]N7Y <br /> ENVIFiONMEN7AL <br /> ACCEPTED BY: EMPLOYEE#: DATE: " <br /> ASSIGNED TO: EMPLOYEE#-. DATE: // <br /> Date Service Completed (if already completed): SERVICE CODE: <br /> PIE: <br /> Fee Amount: �" Amount Paid " Payment Date Z� I <br /> Payment Type IT <br /> Ir�vaic # O Check# R Ceived By: <br /> woo 0 <br /> EHD 48-02-025 SR FORM(Gj Iden Rod) <br /> REVISED 11/17/2003 <br />