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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OP RATOR <br /> -fl*- <br /> Group w;K CHECK If BILLING ADDRES <br /> FACILITY NAME r <br /> TW- WlXnc.. Ctrov - R. <br /> SITEADDRESS I DE Hwy au R <br /> Street Number Direelion 1 f 366 <br /> Street Name � 2i Cade <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Scree[Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> I <br /> �7 n TA - <br /> PHONE#2 EXT. BO DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> -To <br /> s1 l yr CHECK If BILLING ADDRESS <br /> BUSINESS NAME r1� PHONE# EXT. <br /> Iv fi W,Cc huat f Or.h - v 1o3 <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ye&Sl STATE C ZIP OS371 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/Or pr0)ect 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 Codes, Standards,STATE and FEDERAL`I Ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPE ATOR/MANA ER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,p of 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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: L <br /> COMMEN S: RECEIVED <br /> ,7/ <br /> e�' <br /> '' M1� 11V1 � ` MAR 24 2097 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: <br /> ASSIGNED TO: (IUW EMPLOYEE#: DATE: <br /> Date Service Completed (if already comp+ d): SERVICE CODE: 'L PIE:Ou Q <br /> Fee Amount: z,-- Amount Paid S-,5-6 •t9 Payment Date 3 r ( 17 <br /> Payment Type C Invoice# Check# cl 6 [ S- L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />