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SAN JOAQUIaUNTY ENVIRONMENTAL HEALT,�PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ocA<H181 S-17 ZtJ _ <br /> OWNER I OPERATOR <br /> W, 67 � 7-2— CHECK If BILLING ADDRESS Ek <br /> FACILITY NAME �Z !� S <br /> S I 3Z ADDRESS-S- `� �T � f�A c—Y 19y3o q <br /> Street Number Direction Street Name Ci -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 APPLICATION# <br /> (oZ6 (F32- Z�r2� a S d 90 <br /> PHONE#TEXT• BOS DISTRICT L&CATION CODE <br /> 7 <br /> 9A tFl- 7 , / GGA <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REGlUESTOR t lGl CHECK if BILLING ADDRESS <br /> BUSINESS NAME� / � �„� PH NE# � Exr. <br /> ( f F-9 2- <br /> HOME <br /> HOME Or MAILING ADDRESS PAX <br /> f <br /> 16-Ty <br /> 1-3 dC�' STATE f�J�J ZIPS <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 Or <br /> 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 Cowes,Standards, STATES and FEDERAL laws. ' <br /> APPLICA.NT'S SIGNATURE: , i�. DATE: /d//q l0 <br /> PROPERTY/BUSINESS OWNER Oi� OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT 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 enviromnentallsite assessment <br /> infonnation 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: <br /> COMMENTS: <br /> R ECE VED <br /> OCT 19 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: d C- EMPLOYEE#: 3 DATE: l! `C-) <br /> ASSIGNED TO: -7- St o-? u"Q EMPLOYEE#: O�C5 DATE: r0P7Q t� <br /> Date Service Completed (if already completed); SERVICE CODE: 3 is P1 1 <br /> Fee Amount: Amount Paid 0 f,T' " Payment Date p I <br /> Payment Type ,� Invoice# Check#��-(�9--7 Received'By:" <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />