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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> _ ifan 7j6 y 5- <br /> OWNER/,OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> V' Street Number Direction Street Name L� �OC�`(c.'i'�i Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 3�R`7 Co <br /> PHONE#2 EXT BOS DISTRICT LOCATION CODE <br /> 2_8 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> N , p�4D — r� CHECK if BILLING ADDRESS <br /> tn <br /> BUSINESS NAME V l5 S ro citt '`--�1 PHONE# EXT, <br /> HOME or MAILING ADDRESS FAX# <br /> Yis+D I ( > <br /> CITY C'l/ /�A— 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 /> 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: ( IO (^. DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sigh 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 assessm0.'r.,' <br /> ation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it IS available and at the Same time It IS my representative. <br /> TYPE OF SERVICE REQUESTED: pU U ' 'C,� ,- MqR <br /> COMMENTS: j/E' <br /> q'i1'10-9 <br /> N JO <br /> Q P g "V HF�Ny CO <br /> ry <br /> pgRTME T <br /> ACCEPTED BY: Lv_ EMPLOYEE#: DATE: a tp I } <br /> ASSIGNED TO: �1ne���Vi� EMPLOYEE#: DATE: J <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: t" <br /> Fee Amount: p Amount Paid Payment Date 3 r p t <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />