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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> Q�0��� l I I�,`n ,J� CHECK If BILLING ADDRESS <br /> G -ll�--vtL(/ <br /> FACILITY NAME `— G t L <br /> ► � 5 <br /> SITE ADDR 7) / I ,O S AC 1 u'r Cr 1. 0 l/ 0 G y) u <br /> vC `9f treet Number Direction / Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (IfDifferent from Site Add <br /> a bCa�- <br /> res ) <br /> ( .3 Street Number Street Name <br /> CITY STA E ZIP <br /> J Dc v c o <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (5ld O I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> / RilY�t/vV- l �iVCHECK if BILLING ADDRESS <br /> BUSINESS NAMEl/ J PHONE# _ EXT. <br /> T-)1 t V i l [. o L (,!)I <br /> J I <br /> HOME or MAILING ADDRESSFAX# <br /> (aA �oc�,� ( ) <br /> CITY �- o C ]� c STATE ZIP 2 <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 /> 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 /> COUNT) Ordinance Codes, Standards, S ATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 10 - - <br /> PROPERTY/BUSINESS OWNERPERATOR/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 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 to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ��C� �L/C/�� .Y�/IC�)���i'�f PAYMENT <br /> COMMENTS: RECEIVED <br /> OCT 26 %Jia <br /> SAN JOAOUIN COUNT( <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: _ EMPLOYEE#: DATE: I <br /> ASSIGNED TO: t W 1 L��nI `n l'�cc'f-� EMPLOYEE#: DATE: I C> <br /> Date Service Completed (if already completed): SERVICE CODE: ,t(�j PIE: Ic"I`- J <br /> Fee Amount: ��� •C�'� Amount Paid 1 Payment Date <br /> Payment Type ! Invoice# Check# Received By: <br /> L <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />