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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> EAV00 640 -')X&b qq 95 <br /> OWNER/OPERATOR ` 'She y- <br /> W 'rf 3 CHECK If BILLING ADDRESS 0 <br /> 5 <br /> FACILITY NAME Q 6 I koy-rlk'>N RJ S-f¢ I St S,4 teO /l CA �r,- <br /> SITE ADDRESS V <br /> Street Number I Direction I Street Name city Zip Code <br /> HOME orMAILINGADDRESS (If Different from Site Address) /� C(1 -I Z 12 <br /> J 7 Vv\0 If ', r Street Number 15t `'e� StreetNameName 1 <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> (2Q`) - 2 6 8i <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS 0 <br /> P"Y1 t UWI <br /> BUSINESS NAME PHONE# EXT' <br /> HOME Or MAILING ADDRESS FAx# <br /> t ) <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)) °I.and FEDERAL laws. <br /> � <br /> APPLICANT'S SIGNATURE: ,bLP/( I�mil DATE: <br /> PROPERTY/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 assessmentinfo ion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provide"-f0 <br /> my representative. ' � 11 F� <br /> TYPE OF SERVICE REQUESTED: 160a � � `-'✓/"IPW� F c r <br /> COMMENTS: ? O <br /> y���tiFN�� B <br /> ACCEPTED BY: Ir EMPLOYEE#: 90w DATE: <br /> ASSIGNED TO: .l-t '6 EMPLOYEE M /00 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: - P/E: 0� <br /> Fee Amount: JC ` Amount Paid � PaynferttDate 2 / <br /> Payment Type (7,�< Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />