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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 I OPERATOR� CHECK If BELLING ADDRESSO <br /> FACILITY NAME 1 a /� C� <br /> SITE ADDRESS '/5� �I s'���C�T � Z-f' <br /> 141W Street Number erection Street Name Ci Zi Code <br /> Honor MAILING ADDRESS (If Different from Site Address) <br /> 30 q L1lY Streetumber Street Name <br /> CITY STATE Zip C r ' I-t <br /> r <br /> PHONE#1 EXT. APN X LAND USE APPLICATION# <br /> 0`70�3`� N` <br /> PHONE p2 EXT. BOS DISTRICT LOCATION CODE <br /> f ( } V06O — <br /> i° CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J�� / t CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> l HOME or MAILING ADDRESS FAX# <br /> ( Zoll) 334— 0-7z3 <br /> CITY w 1 STATE Zip <br /> BILLING"ACKNOWLEDGENTENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> I 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 /> 1 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,Stand rds,STATE and FEDERAL laws. <br />` APPLICANT'S SIGNATURE: _ IN DATE: l rt <br /> PROPERTY/BUSINESS OWNER❑ O BATOR/MANAGER ❑ OTHER AUTHORIZED AGENT [.�1 U I L � d <br />[ IfAPPLICANT is no e B LING 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 /> i 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 /> E <br /> TYPE OF SERVICE REQUESTED: C/l ENT <br /> f COMMENTS: �O]r`1(/Tt k} / p� R GIVE <br /> MAY 17 2007 <br /> 09 41/�1� _ SFW JOAQUIN COUNTY <br /> ENVIRONME TTA T <br /> ACCEPTED B � EMPLOYEE#: 0 DATE: i <br /> Off <br /> ASSIGNED TO: �(�~ EMPLOYEE#: J/ [)ATF: <br /> Date Service Completed (if already completed): SERVICE CODE: 2PIE: 6 ` <br /> Fee Amount: ;�Y 751 Amount Paid 5 , Payment Date S t� <br /> Payment Type ✓ Invoice# Check# g 3 f\'!i Received By: <br /> EHD Q8-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />