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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Lr-t'ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -FA 0022gJ9.0ogo3 Lq <br /> OWNER/OPERATOR /'�(� f dl e—b J/1 . CHECK if BILLING ADDRESS <br /> FACILITY NAME /i0 1 tk O�l fL* 5 ��I G 4 0 0 1ty2-�' <br /> SITE ADDRESS C) S /`/�I l �a4/111a4/111.,X <br /> Street Number Direction (./ Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 2�l� W l _ t-p <br /> Street Number PSStreletvNa`m-e <br /> CITY STATE CA ZIP /7h,.-ZO(-A <br /> P,�xi�#1 <br /> EXT* qpN# LAND USE APPLICATION# `�1 lJ <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR i�C�, �l Ili 4 CHECK if BILLING ADDRESS <br /> BUSINESS NAMEi\/JI P11n VI'l �l l7 j �(.�fLbt)�IOP # �g��g/a�� ExT. <br /> HOME or MAILING ADDRESS S '�1 l ("Z �} FAX# <br /> ( ) <br /> CITY STATE CA,�- 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. <br /> APPLICANT'S SIGNATURE: (tel tr 9 S- act � - DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 11OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 7'fr[e <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 asses ent information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It IS i *, or <br /> my representative. `� <br /> TYPE OF SERVICE REQUESTED: VUO v veld V c l vc - pr% <br /> COMMENTS: S Z 2®/n <br /> NVIAQU/N CO J <br /> H�CTH�EPM, NiY <br /> ACCEPTED BY: l�'�jV�� EMPLOYEE#: DATE: 12 l <br /> ASSIGNED TO: M o vv�YzCJ EMPLOYEE#: DATE: l <br /> Date Service Completed (if already Completed): SERVICE CODE: ao PIE: I V <br /> Fee Amount: I JZ, Amount Pai /�� �� Payment Date /f <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />