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SAN JOAQUIIV COUNTY ENVIRONMENTAL HEALTH br-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# U�/ RVSSERVIQCE REQUEST# <br /> OW 70 <br /> OWNER/OPERATOR 1 A <br /> L/1 n f� f cj],cz - /, CHECK if BILLING ADDRESS EJ <br /> FACILITY NAME ' \�(P (/L <br /> SITE ADDRESS � , , 1 C'*e , W e <br /> ` 1�L_•� C�fC <br /> Street Nu ber Direction IrJ I Street Na L city Zio Codeb <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Z! (t 1 Street Number Street Name <br /> CITY STATE ZIP <br /> S� ,n CA CIT20 - <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( <br /> 056a Y, 11CitO <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> Kir I <br /> BUSINESS NAME �,.`� PHONE# EXT. <br /> I 2011 W 1 55 <br /> HOME or MAILING ADDRESS FAX# <br /> e Loa <br /> c ) <br /> CITY STATE !' ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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: t\-Aa,6c!i(/7 /cme-n c-( 6( DATE:t-!I- / 13 <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 assessmA fpynation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It IS pr <br /> my representative. `��� <br /> TYPE OF SERVICE REQUESTED: �V, J <br /> COMMENTS: SqN JO ?� <br /> N A) l e r ENVIgQU/N C <br /> y�GTy p PMR 7k <br /> NT <br /> ACCEPTED BY: S EMPLOYEE#: ! � DATE: <br /> ASSIGNED T0: A EMPLOYEE#: I3-3b/ DATE: IW/9 <br /> Date Service Completed (if already completed): SERVICE CODE: S PIE: <br /> Fee Amount: '(/(f 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 />