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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Businessor roperty FACII ITY ID# SERVICE REQUEST# <br /> . S 3tv s' SP-06 7 a�a <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME CV ItAl <br /> M <br /> SITE ADDRESS C uu ®� r L C �� <br /> Str¢et Number DlrecHon reel Name otle <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#t �r J QyT' APN# I �'/-� LAND USE APPLICATION# <br /> PHONE#2 Ext• BOS DISTRICT 1 LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR `-� ( t;` yi <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME rl,�y, IIA C PHONE# ExT' <br /> HOME Or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE 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,STATE and FEDERAL laws, <br /> APPLICANT'S SIGNATURE: y) W -1-L, DATE: <br /> PROPERTY I BUSINESS OWNER 11 OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me Or <br /> my representative. All <br /> c <br /> TYPE OF SERVICE REQUESTED: %0441`- <br /> COMMENTS: � VFX <br /> S <br /> hRQi//N <br /> B9(TH I MRNT /Y <br /> ACCEPTED BY: .., V EMPLOYEE#: DATE: <br /> ASSIGNED TO: t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: (6 Q E: 2- <br /> Fee <br /> Fee Amount: D Amount Paid $ aoq — P �ayment Date / 1� <br /> Payment Type C_ C Invoice# Check# Tµ qq l g y Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />