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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 10 PERATOR <br /> Gka Vel G –1 \ CHECK If BILLING ADDRESS <br /> FACILITY NAME `511A ��(•�_ l }— �? 7 <br /> SITE ADDRESS l Cl�.a At ,AR,r3 /SJ et NumberF-S <br /> Direction V Street Name / lv <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ! EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> &'Vy�t— <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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 Is pplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standa ds, TATE and FEDERAL la <br /> APPLICANT'S SIGNATURES 'ct r DATE: G j-- <br /> PROPERTY/BUSINESS OWNErff OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ ' <br /> If APPLICANT IS Wt 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 I r lI 1 d to me or <br /> my representative. l�W,(--- <br /> TYPE OF SERVICE REQUESTED: ( 9 <br /> COMMENTS: MAY 0 5 tot, <br /> SAN' AQUIN COUNTY <br /> ENVIRON' <br /> F.EA TH DE AETMENT <br /> ACCEPTED BY: h EMPLOYEE#: 2 j DATE: <br /> ASSIGNED TO: EMPLOYEE#: cG 9 DATE: <br /> " <br /> Date Service Complete (if already completed): SERVICE CODE: v( _ PIE. <br /> Ct <br /> Fee Amount: �,) Amount Paid--/ / 9 >� Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />