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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i e�-vt U Vial T 1 -_2-► ':�-� Sic,700 73 SS' 7 <br /> OWNER/OPERATOR A l'�u(b�ts c o 74 lcoa 'tj-I/ V, 1 <br /> 7-t I�/l//(•(_ I CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS w <br /> Street Number Directio.n Street Name II Cit �� Zi Code <br /> HOME MAILING ADDRESS (If Different from Site Address) 2- � KeI 6 <br /> ZIE 1 W,9 Street Number J 01 Street Name <br /> CITYLlt1 /�, ��/ STATE ZI <br /> V m <br /> PHONE tj EXT. APN# LAND USE APPLICATION# <br /> c_�2g22-3y-2U 21 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR y <br /> I (/�1 rVAHECK if BILLIN ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS 11,g FAX# 1�/ <br /> CITY <br /> LoopSTATE�'/]_ ZIP <br /> b — J <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business ow e , opefator 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 /> also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAOUIr <br /> CCJNT r Crc mance Codes, Standards, STATE and FEDERAL laws. <br /> AE PLICANI'S SIGNATURE: J DATE: <br /> PROPERTY/BUSINESS OWNER ERATOR/MANAGER OTHER AUTHORIZED AGENT ❑ "' _ <br /> If APPLICANT Is n t the BILLING PAF,Ly.proof of authorization to sign is required Title <br /> AU7H%�RIZATION 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 /> to the SAN JOW)UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is providec to me or <br /> my representative. <br /> PAYM�^� n ENT —I <br /> TYPE ., SERVICE REQUESTED: F�'iLLr' ��E'C� Q cs�' to <br /> TYPE <br /> I�-C-OMMENTS: -� <br /> DEC 15 2015 1 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPAgTMENT <br /> ACCEPTED BY: - J 1 EMPLOYEE#:` DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date F arvice Completed (if already completed): SERVICE CODE: z=",`, P I E: <br /> Fee Amount: 5,6J Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />