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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/OPERATOR , ( / / I_/I `, <br /> RAMCEt L �I�� L rAM(Lr TZ(t& CHECK if BILLING ADDRESS <br /> FACiLQY NAME <br /> SITE ADDRESSIG' /"�.t L IV <br /> //V)C9�2 <br /> Street umVVb`erT Direction Street Name city Zip <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 /> ( ) !05 _ 020- 0 <br /> PHONE#2 ET. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> z x L <br /> BUSINESS NAME PHONE# Exr' <br /> (2a9) Co(c1 <br /> HOMEr MAILING ADDRESS FAX# <br /> 1928B7"'L,EX4,EN LfINc SUiTr E (209 ) 334- 6'323 <br /> CITY L U / ^ STATE /' ZIP 9S-241 S2l <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 ppformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STATE WED I. <br /> APPLICANT'S SIGNATURE: I t65 DATE: (o - 2 ( � C� T <br /> PROPERTY/BUSINESS OWNER OPERATO AGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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: S CA t2F.4c- ,d [ 6,v --,,A-„c.Y <br /> COMMENTS: R ECEI V <br /> �y JUN 2 1 2007 <br /> a�lea d+w"t SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> TH DEPARTMENT <br /> ACCEPTED BY: -T/E� EMPLOYEE At: 7 377 DATE• �, 12--,16 -7 <br /> ASSIGNED TO: (,t its r EMPLOYEE#: J9 3 Z/ DATE: &12W07 <br /> Date Service Completed (if already completed): SERwcECODE: ,3(J�' PIE: oO3 <br /> Fee Amount: 1 Z v --ov Amount Paid b Payment Date <br /> Payment Type ✓ Invoice# Check# 3 Receive By. <br /> EHD 48-02-025 SR FORM(Golden Rod) ' <br /> REVISED 11/17/2003 <br />