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DATE: /*/ // 7 <br />OPERATOR! MANAGER E1 OTHER AUTHORIZED AGENT El <br />APPLICANT'S SIGNATURE: <br />PROPERTY! BUSINESS OWNE <br />If APPLICA T is n t the BILLING PARTY proof of authorization to sign is required <br />Title <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />......., <br />,. ,-I r La I— ii ,r" (--' ,- <br />FACILITY ID # SERVICE REQUEST # <br />10,w,NER 4 OPERATOR _ <br />tia9J2_,_ -0.---"' <br />.C- 1/-21-6 U C <br />— <br />CHECK if BILLING ADDRESS <br />1._ <br />FACILITY NAME • <br />LC) S2_ -Z---- -(i_- <br />SITE ADDRESS <br />Street Number Direction 7-1-C.If Street Name Li , / "./ C-1 /\ i 7 7 ip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />c--.) LA 0UL- Street Number Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />---- ()CCP Cr--Y5D-- ._-) LI '-) 7) <br />APN # LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />\ - ' ( (Z) ( - ---Z--- <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME <br />( <br />PHONE # <br />..-I s-07-4- <br />EXT. <br />Li --2,.., <br />HOME or MAILING ADDRESS Fax # <br />CITYc <br />i <br />STATE <br />c • rt <br />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. <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 to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: \ V ahick, , <br /> <br />1/)..9p_e_ch a v/ CEA/to COMMENTS: <br />L t & ir 7 tA ) Lj 4 Z 201? <br />S A N:IJOE Al'IQ : 70 U N 7- Y r) <br />ritALTH ''NMENTAL <br />DEPARTMENT <br />ACCEPTED BY: (74 EMPLOYEE #: DATE: <br />c2 <br />' c:7::/ --) <br />ASSIGNED TO: <br />I EMPLOYEE #: <br /> DATE: ) ,,,,a _T.-, <br />Date Service Completed (if already completed): SERVICE CODE: (,..-- NE: 1626)3, <br /> <br />Fee Amount: / -,.c ..--- <br /> <br />' - i <br />Amount Paid 1,- 1 3q . Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />07/17/08