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SAN JOAQUivi COUNTY ENVIRONMENTAL HEALTH L tPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rJoto K C6-)gas-_�:) <br /> OWNER/OPERATOR pO <br /> T�r///2 S_ <br /> I/1 ' " O I\\1 CHECK If BILLING ADDRESS <br /> FACILITY NAM/E' �V� / <br /> e,)< <br /> i_ e GI� � <br /> SITE ADDRESS <br /> i reet Number Direction I Street Namecity Zip Cndo_ <br /> HOME Or MAILING ADDRESS (If Different from Site Address)17) b <br /> 2 r/ /V\ r 1 / Street Number Street Name <br /> CITY STATE ZIP <br /> Sic+ � 0 -YN A �5�1a <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 00q) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,t <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAME , PHONE# Ext. <br /> HOME or MAILING ADDRESS FAX# <br /> ! � ( ) <br /> CITYN O STATE 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 /> 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. 1 <br /> APPLICANT'S SIGNATURE: � : j�5e ')- _ S 1�!)0 n DATE: �- ZL1-J LP <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 t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: liGl� <br /> PAYMENT <br /> COMMENTS: RECEIVED <br /> bc,#t CO64� r7tol FEB 26 2iv;r0' <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> 'ri All IH I RTMENT <br /> ACCEPTED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: ? EMPLOYEE#: DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: O / PIE: <br /> Fee Amount: 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 />