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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#C <br /> OWNER/ OPERATOR <br /> CHECK If BILLING ADDRESS El <br /> 1)J/R- IV /P71,7 S• <br /> FACILITY NAME /3 2 <br /> c <br /> SITE ADDRESS �N-,7 G ="• '` " " <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) *0-53 �j 7—EIAIE0 a <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> (0Q 9� 32c� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# O 7— <br /> o -- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) o w <br /> CONTRACTOR/ SERVICE REQUESTOR �— <br /> REQUESTOR <br /> D0 1v CWG wl-r CHECK If BILLING ADDRESS \� <br /> BUSINESS NAME / PHONE# EXT. <br /> ) ldo3 <br /> HOME Or MAILING ADDRESSFAX# <br /> o ' �7 4 _Z� <br /> CITY STATE CA <br /> 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 applica ' n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA nd FEDE aws. /y <br /> APPLICANT'S SIGNATURE: DATE: <br /> j/ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ IIER AUTHORIZED AGENT CJE <br /> If APPLICANT is not the BILLING PARTY,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: 5 CE Ft SG(13Su��q c� ea,%I Ti4 m l NArfCAI REPoaT �?���F <br /> COMMENTS: ✓rt�,/`�V,1/4 �'W RECEIVED <br /> As h NOV 2 7 2006 <br /> SAN JOAQUIN COUNTY <br /> // ENVIRONMENTAL T <br /> ACCEPTED BY: EMPLOYEE#: C/ ATE: <br /> ASSIGNED TO: a i S EMPLOYEE#: L1/3 DATE: <br /> Date Service CompletedplG'_—(if already completed): <br /> SERVICE CODE: ` P 1 E <br /> Fee Amount: Amount Paid D Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />