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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> skmq?s <br /> OWNER/OPERAT <br /> n CHECK If BILLING ADDRESS <br /> JP�An05 SZ,�VC' C�l� CovrS�. <br /> FACILITY NAME <br /> S oI rto5s v e_ .Gn ;:' Course, <br /> SITE A RES ? ,�._ 61;: - 1 t�Q '\ &TSZ i� <br /> Street Number Direction .JJ Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address -rryPCA(-" ";-"q <br /> loloo 1 1^1 fl C �/�JC S �v Street Number Street Name/ <br /> cITY5�k�n ST zIP,-r '^ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# J `� <br /> (") -`i7b -7cl5 q OSS- Z p--G 1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> tI 1� CHECK If BILLING ADDRESS <br /> BUSINESS NAME ` PHONE# EXT. <br /> -Ca( U vt-v-C-5 r1L -,; L Z <br /> HOME or MAILING ADDRESS FAX# <br /> 3 ev.i�ron ( ) <br /> CITY -11 �c-K\_0 / C STATE I\ ZIP S-2JC! <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized argent 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 ap tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar S ATE arld,FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /�I r <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/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 asse n Information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It I ME, r <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ! <br /> COMMENTS: V_ /'-!/ 1 �� <br /> � � SAN JOAQUIN COUNT( <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: �`J� EMPLOYEE#: /� DATE: D <br /> ASSIGNED TO: •� EMPLOYEE#: (/ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: �Z P 1 <br /> Fee Amount:TT C) Amount Paid I) Payment Date �- <br /> Payment TypeV Invoice# R# Y l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />