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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY I{)# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> / / CHECK if BILLING ADDRESS O <br /> RC ��S <br /> FAcllm NAME <br /> SITE ADDRESS <br /> Street Number Direction' Street ame `� ' Citv Zin Code <br /> HOME Or MAILING ADDRESS (If Differen from Site Address)/lot 5 <br />� Street Number Street Name <br /> CITYr STATE zip <br /> 4sG3z <br /> PHONE#1 EXT ARN# Z 34)- a I LAND USE APPLICATION# <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> { } <br /> i CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 4— �/rJi7l� <br /> k-12� CHECK If BILLING ADDRESS <br /> BLISINESSNAME /1 �LL V &'' PHONE# E"T I <br /> q 71-- 6'f Z3 <br /> HOME or MAILING ADDRESS _ + I k FAx � <br /> '544a r 1 &!Icit �f ) 4?-31— �7-3/r 0 73 <br /> CITY fz> k 4O _ STATE . ZIP <br /> BELLING 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 applic tion and that the work b performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, and FE L law <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Cry 11L x/ 61e . <br /> If 14PPGICANT is not the BILLING PARa proof of authorization to sign is required Title <br /> AUTHOI.UZATION TO RELEASE INFORMATION: When applicable, I, the owne/na <br /> erator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnicata an or <br /> envirourrlental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as so it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: /�)e&.Y <br /> COMMWS: r . <br /> 0/10 RECEIVED <br /> ,31 � �� �"`"✓� JUL 2 2 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL, <br /> ACCEPTED By EMPLOYEE#: <br /> ASSIGNED r0: j EMPLOYEE#: r DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �Z P I E: �d <br /> Fee Amount: <br /> Amount Paid Payment Date 7 <br /> Payment Type u/ Invoice# Check# �c '� Received i y:�' <br /> EHD 48-02.025 SEtQftM:(Golderi fad) <br /> REVISED 11/17/2003 <br />