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SAN JOAwJIN COUNTY ENVIRONMENTAL HEAL'I r. DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/O RA OR <br /> 0. <br /> CHECK If BILLING ADDRESS <br /> SA <br /> FACILITY NAME A7�A <br /> SITE ADDRESS Zisi(//'lu ](� l /� W <br /> SkeetTlumber DKection G S reef Name Ci yi CodeW <br /> HOME or MAILING ADDRESS (If Different from Site Address) ////�� <br /> GStreet Number G Strbet�Name <br /> CITY SrAJE ZIP' <br /> u�j� � ExT• APN# / J� LAND USE APPLICATION# <br /> P/Y//'0 7 l// W.1-:)-0 <br /> PHONE#2 EXT. BOS DISTICT LOCATION DE <br /> ( ) .. (a( <br /> 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> /tq- <br /> BUSINESS NAME /� {) P Ex <br /> HOMEOJ�MAILING ADD ESS FAX# <br /> L( ZJ t ( ) <br /> CITY ST TE ZIP G M-- <br /> BILLING <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 preparedIthissplication d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, StandaATE and ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /2- <br /> PROPERTY/ <br /> PROPERTY/BUSINESS OWNER APER O ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required Tifle <br /> AUTHORIZATION TO RELE4SE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> site address, hereby authoriz e-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 to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: e {3 <br /> COMMENTS: '1 <br /> L I� c�b��� M I sem,°�c <br /> ,? V ° <br /> ti��N�°qo uI ��, <br /> R N <br /> TyF,yoUN <br /> ACCEPTED BY: C��rj EMPLOYEE M DATE: <br /> ASSIGNED TO: --/� EMPLOYEE#: DATE: <br /> Date Service CompletedJ(if already completed): SERVICE CODE: n P I E: „GI� <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 />