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SAN JOAQ%-..,, COUNTY ENVIRONMENTAL HEALTH II.,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property n FACILITY ID# SERVICE REQUEST# <br /> 0001511 <br /> OWNER/OPERATOR r CHECK If BILLING ADDRESS <br /> CL� <br /> L CA� <br /> FACILITY NAME <br /> Q CZl l.,tC"- <br /> SITE ADDRESS <br /> 3 Qtreet Number Dir ;6. X t Name <br /> HOMJ Or Mmi ING ADDRESS (if Different from Site Address) — <br /> Street Number <br /> CITY — — (� STATE ZIP <br /> PHONE#11 EXT. rFN# LAND USE APPLICATION# <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR /J <br /> V�C �o_ r' CHECK If BILLING ADDRESS <br /> BUSINESS AME V (CGXYY KG r PHONE# EXT. <br /> ua a CL i6 7 <br /> H0,ME or MAILINp ADDPtSS FAX# <br /> G v c O ( ) <br /> CITY i ' $ TE ZIP <br /> G , <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 an hat tvj'xot <br /> be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE and FED AL <br /> APPLICANT'S SIGNATURE: _ rt'' DATE: C) v t/—l� <br /> PROPERTY/BUSINESS OWNER❑ OPERkr61R/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. P <br /> TYPE OF SERVICE REQUESTED: CC <br /> COMMENTS: <br /> RAY o <br /> ff VF <br /> s 4 ?0 <br /> 'tii 'YON fN COU, <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 6 ' PIE: <br /> Fee Amount: Amount Pai � �� j5 Payment Date .�'�/ <br /> Payment Type ,< Invoice# Check# Received By: / <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />