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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPA-TMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> FP( 0c22C�C91D SIz 00&-)�A <br /> OWNER/OPERATOR <br /> m©ori CHECK if BILLING ADDRESS <br /> FACILITY NAME (� i — -\ — seo <br /> SITE ADDRESS 12 C'q I 1 R�;n <br /> ` A ;4 . � �� <br /> -T <br /> Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) -2 <br /> 2- <br /> Street Number V l� Street Name <br /> CITY STATE ZIP <br /> CA1 <br /> PH # EXT. APN# LAND USE APPLICATION# <br /> T� J-1-2L <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> • CHECK If BILLING ADDRESSE] <br /> 1 0-01 v <br /> BUSINESS NAME � — f,'D /� P 0 � g� -2o�—' T <br /> HOME or MAILING ADDRESS / I "i /.� FAX# <br /> CITY STATE /1/1 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, ST TE and F DERA.L haws.. 7 <br /> APPLICANT'S SIGNATURE: j 7 DATE: ! - 3 J�� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to sign is required Tirle <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time�� �me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: REd valkctc ` (lam\ <br /> COMMENTS: U <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: N' V EMPLOYEE#: DATE: 1 1 <br /> ASSIGNED TO: '� S An EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: I PJ.E: U1 <br /> Fee Amount: lr� �SL 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 />