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SAN JOAQUIN L;OUNTY ENVIRONMENTAL HEALTH DErARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> UkLpU+ <br /> OWNER/OPF!B�p'TOR <br /> ^ CHECK if BILLING ADDRESS <br /> FACILITY NAME LR2 l l (� no <br /> SITE ADDRESS /--Ll-(c) S A 1'(P C r,-� V'1 Ct J S toc,�--tn <br /> Street Number Direction I Street Name Ci Zip Code <br /> HOME Or AILING ADDRESS (If Different from Site Address) <br /> l� 3 ma( T ' 7 <br /> H � <br /> Street Number Street Name <br /> CITY C � � STA T ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (2(m) `a <br /> PHONE i/2 EXT• BOS DISTRICT LOCATION CODE <br /> (1 )'27:� AA&/4 1✓► — E i,5 k-) <br /> 2�s, CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ^_ <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME I � PHONE# � I _� � EXT. <br /> HOME(�r MAILING ADDRESS FAX# <br /> 1 ?) M 1 S4 ( ) <br /> CITY ST/}7yi 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �4^. Ct DATE:� 9-d/2 <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El <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 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 b me or <br /> my representative. /q <br /> TYPE OF SERVICE REQUESTED: �r <br /> COMMENTS: <br /> -7 �S �3 s,�✓ FC <br /> ti FM�°R QU,,y ? 8 <br /> CO, <br /> N <br /> r'yF <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: 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 />