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SAN .IOAQUIt. COUNTY ENVIRONMENTAL HEALTH MARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> BUJ A N 5 NoC�' �GW 5�� 1Z <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> u'�ts� SITE ADDRESS <br /> I F( A 0 Pf N 1-11 D S,Izc`t-Tw '5 215 <br /> C'Q Street Number Direction Street Name CI ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Y ` Street Number Street Name <br /> CITY STATE ZIP <br /> � S -3 7 6 <br /> n� PHONE'F! EXT. APN# LAND USE APPLICATION# <br /> _ 2 o� `7C� <br /> PHONE#2 / v EXT. BOS DISTRICT LOCATION CODE <br /> (C - C r I, O " <br /> U CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR, I f n <br /> GV �/ CHECK If BILLING ADDRESS <br /> BUSINESS NAME ( t` ✓I PHONE# EXT. <br /> -- OAWAklilo vw CN�-5 2 , a 0 07 15 o <br /> HOME or MAILING ADDRF�SS FAX# <br /> CITY STATE 6 ZIP 5 <br /> BILLING ACKN WLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONM HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified thi r . <br /> also certify that I have prepared this application ha-Nh o to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and F ERA I J� <br /> APPLICANT'S SIGNATURE: _ DATE: 0 <br /> PROPERTY/BUSINESS OWNEROPERATOR I MA NA ER 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. <br /> TYPE OF SERVICE REQUESTED: �� / /, �m �� PAYMENT <br /> COMMENTS: RECEIVED <br /> JUL' 2 1 , <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE' <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed If already completed): SERVICE CODE: - PIE: 03 <br /> Fee Amount: (V,00 Amount Paid 3 � Payment Date — <br /> Payment Type ' Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />