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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH U•EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS O <br /> FACILITY NAME i <br /> u-i Srr <br /> SITE`ADDRESS (//� /�//►�/ �c <br /> /J W (—"'s4ef Timber Direction Street Rame • +�� �"�/' Zi Code <br /> HOME 0 MAILIN ADDRESS (If Different from Site Address) <br /> Street Number C°�L//"/, Street Name <br /> CITY STATE ZIP <br /> /P <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> VO ) S-2-7- 6000 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / SFry ` ,y <br /> ' /` �� J /• /� /�' J�1!/�n� CHECK If BILLING ADDRESS LI <br /> BUSINESS NAME - P E# EXT. <br /> 115-(- <br /> HOME or MAILING A-wKESS / FAX <br /> �3��� �l/. l�/b - ►,J i �T/c��• -tt (Si) uN - 11.15 — <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 ChargP,S associated with this project or <br /> activity will be billed to me -r my business as identified on this form <br /> ' also certify '.hat I h<ve prepared this application and that the work to performed will be done in accrrdance :'lith all SAN JOAOUIN <br /> COUNTY Ordinance Odes. Standards, STAT EDERAL laws % <br /> I APPLICANT'S SIGNATURE: � DATE: <br /> r <br /> PROPERTY/BUSINESS ONINER❑ OPERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT <br /> \• <br /> If,IPPLIC 'NT Is not the BILLING PARTY,proof of authorization to sigin is require? Tit7'-- <br /> AUTHORIZATION TO RELEASE INFOF'RATION: When applicabl3, I, the owner of operator of 1 e prone ty 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 JOAQUIN COUNTY Ei,4VIRONMENTAL HEALTH DEPARTMENT as Soon a5 It IS available and at the same time it is p ovided to me or <br /> my represF tative. PnV14ACA1T <br /> TYPE OF SERVICE RLQUES i ED: _ �1c� (� RECEIVED <br /> COMMENTS <br /> ��04- /vrb��� SJrr-� /On��n/�o t�J OCT-28 2015 <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE:Ii f <br /> ASSIGNED TO: EMPLOYEE <br /> D,-,ie Service Completed (if already completed): I SERVICE CODE: ,� PIF: / D <br /> Fee Amount: \1 9--16•vV T Amount Paid Payment Date ,, j.-a q< <br /> Payment Type Invoice# Check# � (� �'1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />