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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# � SEORVOIC,E REQ9ES <br /> OVI <br /> OWNER 1 OPERATOR <br /> CHECK If BILLING ADDRESS <br /> / ,C ( LAW <br /> FACILITY NAME _ <br /> Ste.✓ ? C'- T/i ufK� ,✓ i <br /> SITE ADDRESS <br /> SIp <br /> �S 7 c' Street Number DI tioo Ra �Street Name, L C��L Zio Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Cc —7 � <br /> .l ��� i / �/ l greet Number /T Streo Name <br /> CITY STATE ZIP <br /> G L r7 <br /> PHONE pl EXT. APN# LAND USE APPLIFATION# <br /> (<< ) y 9-- - c G.S 3 �c 0 f 6 �'� - b OCA0 �-�- <br /> PHONE ill EXT. BOS DISTRICT / LOCATION CODE <br /> c q 9 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> I It, CI (` _ `0^/' `r �. CHECK If BILLING ADDRESS{...I <br /> — (?,/' <br /> ( EXT. <br /> \V, BUSINESS NAME 5 sr/ _ � (2-9 ) <br /> 2 Q ) -5�� <br /> C HOME Or MAILING ADDRESS FAx# <br /> CITY STAT zip �1 , <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 Codesr.Sf� TATE and FEO L laws 1` <br /> APPLICANT'S SIGNATURE: ' DATE: /G— <br /> \ PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C L� �C( C-�v r <br /> I/APPLICANT is riot the B!LLING PARTY,proof of authorization to sign is required 7 irte <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(a me or <br /> my representative. N <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 0 �O <br /> -�SYa�-tris f� �u. f <br /> C PnRo�/N C 8 <br /> lyo q <br /> If <br /> ACCEPTED BY: (Jvi EMPLOYEE#: v I DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 O <br /> Date Service Completed (if already completed): SERVICE CODE: 0b ' P/E: 142 Q�> <br /> Fee Amount: L Amount Pai /sem. �)(J Payment Date <br /> Payment Type Invoice# Ch k# b-�G3d Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17108 <br />