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DATE: S- - / <br /> <br />OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />OWNER/OPERATOR .111._ CHECK if <br />X-9c , <br />BILLING ADDRESS 0 <br />FACILITY NA <br />SITE ADDRESS <br />3/20 /4 7"'" '51/4er/slumber I Direction I ' City Zip Code ' .l'aret Name <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />/9''r 7-,) C,.//es .,4i :20- / 73 Street Number Street Name <br />STATE ZIP 6C TYc, 7/. <br />PHONE #1 EXT. <br />s( 3 <br />APN# LAND USE APPLICATION # <br />PHONE #2 Ex-r. <br />) 5'- 2 9- 5-q <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />1 r? i / <br />CHECK if BILLING ADDRESS <br />---'9-1 c.1 /./2 / l'-) /4 / BUSINESS NAM.PHONE _4.-z-p # <br />(//b ) F2o)- ,-4;2 ( 3 <br />EXT. <br />HOME or MAILING ADDRESS ilro 6, _ / 7 3 Fax <br />(974.) 5.C, 3 z-K 5"-Y <br />crry 6 <br />BILLING 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: <br />PROPERTY! BUSINESS OWNER 0 <br />If APPLICANT iS not the BILLING PARTY, proof of authorization to sign is required <br />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 priyided to me Or <br />my representative. <br />TYPE OF SERVICE REQUESTED: 00ot Ni 2 111C --' i 65p -62h On 11E. CE ....,, . , II/Fa <br />COMMENTS: gdy 0 .0 <br />SAN 1,-, 0 2016 <br />L.:.--,,AQuiA , 14, <br />cALTH <br />cNItiFinlilCOunn i • •, 1 <br />''' ARTAZIA0 <br />ACCEPTED BY: C, ? ra EMPLOYEE #: DATE: 5 ,D ., 1 .,) <br />ASSIGNED TO: <br />VdC11161 <br />EMPLOYEE #: DATE: <br />Date Service Competed (iPalready completed): SERVICE CODE: (,:. / NE: ) <br />Fee Amount: ) -3.t.-- Amount Pai ",y), /)7 ) Payment Date 57 <br />Payment Type Invoice # Check # / 636y Received By: 6,al , <br />11 <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)