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SAN JOAQUIN -,OUNTY ENVIRONMENTAL HEALTH DE. . RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST# <br /> -�-C� L(Lc�wk t S U db200 <br /> OWNER I OPERATOR <br /> J; CHECK if BILLING ADDRESS <br /> F CILITY NAME <br /> SITE ADDRESS C A�;r�„ _ + <br /> 3S �^�Vt <br /> Street Number Direction Street Name city Code <br /> HOME or MAI G ADDRESS (If Different from Site Address) <br /> N� . Street Number ►1 Street Name <br /> CITY STATE ZIP <br /> 37 Cp <br /> PHONE. EXT APN# LAND USE APPLICATION# <br /> c tLVPHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> f a On r\-,) PHONE <br /> ��^+ CHECK if BILLING ADDRESS <br /> BUSINESS NAME ` \ t �• `� PHONE# EXT. <br /> 3 <br /> HOMEO MAILING ADDRESS (AX# ) <br /> CITY I STATE ZIP <br /> BILLING ACKNOW ED EMENT: 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, STATEa F ERAL IaWs. <br /> i 7 <br /> APPLICANT'S SIGNATURE: _ DATE: <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 provld� _me Or <br /> my representative. tY <br /> TYPE OF SERVICE REQUESTED: ' IT�Qenol�T <br /> COMMENTS: MAR 2 8 b <br /> cj/Aa rIq o o�J✓? s�anr J0 18 <br /> E AQU/IV <br /> 11P.46- �O VMS M 11' <br /> 7- <br /> ACCEPTED <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: v PIE: 1 6'a <br /> Fee Amount: i a Amount Pais[ Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />