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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#!! <br /> . b <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 2,/$7.0 67 I"IL-TP/V )2e.440 (,./iiJDE/V grZ340.-. ' <br /> Street Number Direction Street Name city ZIp Cade <br /> i <br /> HOME Or MAILING ADDRESS Ilf Different from Site Address) P O• ZoX ')O 2.. <br /> Street Number Street Name p� - <br /> CITY L rft��� STATE cA ZIP I T`Z 3& <br /> PHONE#t Exr. pPN# LAND USE APPLICATION# <br /> o93-or{o- 53 PA - 08 <br /> r <br /> HONE#2ExT, 130S DISTRICT LOCATION CODE <br /> - <br /> f - <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> TOY <br /> T <br /> BUSINESS NAME E.T. <br /> t PHONE# <br /> HOME or MAILING ADDRESSFAX# <br /> I P. B6X Ugo {moi ) 334-' 7 Z3 <br /> CITY L*h! STATE GIA ZIP 9 y-zf/' <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> kacknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this protect <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: <br /> 1, PROPERTY I S[351NE5S OwNERO OPERATOR/MANAGER D OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING P,RT—Y proof of authorizrttion 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 environmentaVsite 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 /> 4 TYPE OF SERVICE REQUESTED: P, Swr <br /> COMMENTS: RECEIVED <br /> DEC 1 1 2009 <br /> �aM, - SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL' . <br /> HEALTH 0EPARTMEN7.,•_ <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECOOE: �2, p1h: <br /> : l <br /> Fee Amount: ( r� Amount Paid �?� `` Payment Date t I <br /> Payment Type Invoice# Check# Received By: <br /> EHD48-02-025 SR FORM(Go en-Rod) <br /> REVISED 1111712003 <br />