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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> .461elLl'a L VIZAL 51?c0 5 3+ 1 <br /> OWNER/OPERATOR <br /> 1*)�7R CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#I EXT. APN# LAND USE APPLICATION# <br /> (Z09 ) toi3 - Z 5i 9 /✓ ,4 - D19oo q <br /> PHONE#T EXT. 1[i3iDISTRICT 4 [LO�CATION <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �o/`/ /������t CHECK if BILLING ADDRESS <br /> BUSINESS NAME C PHONE# EXT. <br /> HE LO <br /> ' �vSU 1 T N <br /> / 6 ( <br /> C5N� e <br /> HOME Or MAILING ADDRESS FAX# <br /> ( w ? ) <br /> CITY TUR L0 C iC STATE C A ZIP <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 Codes,Standards, S TE andF RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/NIANAGER ❑ OTHER AUTHORIZED AGENT V <br /> If APPLICANT is not the BILLING PARTr proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: SG(Rf/a fi1135 q RF,4 cc Q'/✓T/I IUATi,9AI /lr 1i✓ <br /> COMMENTS: lI 'II'a� If�/Yr.• (i� i ��N7, ��,µ� ' RECEIVED <br /> FED 2 1 2008 <br /> SAN JOACJUIN COUNTY <br /> 3� ,'`�,•t Fi ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 510 EMPLOYEE#: O DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 211 P I E: 03 <br /> Fee Amount: o Amount Paid Payment Date <br /> Payment Type Invoice# Check# $ i Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />