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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/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> �IrrA0. �jpLaicv t-I <br /> FACILITY MAMF <br /> Ile- <br /> SITE ADDRESS <br /> 2�t�ao E Ina+c a —TS locK 1%) ti CA S,?- <br /> Street Number Direction Street Jane city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> \�o W t,,\ ok y—s\v1I-e- b v Street Number Street Name <br /> CITY STAT` <br /> Zip <br /> 7 'E C\S?b 3 Ci <br /> PHONE#1`, EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> �rMa� 'Pjow�:.N <br /> BUSINESS NAME PHONE# EXT. <br /> N1rn2hZ-. CCrw\(r,iCt <br /> HOME or MAILING ADDRESS FAX# <br /> SATE <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 /> I 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. <br /> APPLICANT'S SIGNATURE: .'pr►'ta � DATE: \�"Z('0 <br /> PROPERTY/BUSINESS OWNER L"I OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ r{ <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 i MENT;e Or <br /> my representative. ` �pRECEIVED <br /> L <br /> TYPE OF SERVICE REQUESTED: V Ivy <br /> COMMENTS: �VWp Y d0 of <br /> n G <br /> WW SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: ` <br /> ASSIGNED TO: EMPLOYEE M DATE: � _ N <br /> Date Service Completed (if already completed): SERVICE CODE: O ( PIE: <br /> I u <br /> Fee Amount: C'. n 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 />