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f { <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH L1=NARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> i/ce <br /> OWNER/OPERATOR <br /> Y /Jt ,(�/\6/ 1^ 1, 13 <br /> FACILITY NAM CHECK If BILLING ADDRESS <br /> 1 1 1 11 , Y ` <br /> CITP Annorcc <br /> -firl Direction P '� r 7CI` ZI code <br /> HOME or MAILING ADD ESS)(If Different from Site dress) vV <br /> v�'�t/� ✓ �/ Street Number Street Name <br /> CITY ✓r�v( , ��TE ZIP �,���7 <br /> PH #1#1 ExT• APN# LAND USE APPLICATION# <br /> J -77 "3- <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,�( <br /> I'I ckv\v--\. CHECK if BILLING ADDRES <br /> BUSINESS NAME (J�j �� � 1 P QVE# 76JxT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �y / STATE �7// 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. ,/ Q <br /> APPLICANT'S SIGNATURE: DATE: <br /> % - <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 /> to 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&MENT <br /> TYPE OF SERVICE REQUESTED: P— RECEIVED <br /> COMMENTS: <br /> SPR 1 1 2319 <br /> SAN JOAQUIN C )UNTY <br /> ENVIRONMEN TAIL <br /> HEALTH DEPAR <br /> ACCEPTED BY: L EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: LZI <br /> PIE: <br /> Fee Amount: *14 Amount Paid A y Payment Date <br /> Payment Type Invoice# 771 Chf6k# 3 22- 6, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />