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`JC 'EH- D <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ,(( <br /> \1 CI`VA e v'� /�ck 1 (,(-C) CHECK If BILLING ADDRESS <br /> FACILITY NAME J l!/ Y <br /> SITE ADDRESS \V a <br /> Street Number I Direction Street Name city Zip"Code `i•' <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1'5�) l "S�'- •ncA n a`l 0( .( • <br /> Street"N'❑tuber Street Name <br /> CITY / _ ^ STATE CA ZIP <br /> PHONE#1 Y ` E.T. <br /> N# LAND USE APPLICATION# 'J V��•-' <br /> C3 <br /> PHONE#2 EXT. BIDS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -QtC� CHECK if BILLING ADDRESS <br /> `v1 �.� �_�1� w�iN� <br /> BUSINESS NAME 17 <br /> 1 C <br /> EXT. <br /> HOME or MAILING ADDRESS 1 FAX# <br /> CITY f / ` ��'\ 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 /> I also certify that I have prepare his application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stan ar s, STATE and FEDER ws <br /> APPLICANT'S SIGNATUR : DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is 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 Is. Lid 4L or <br /> my representative. Tit ii�'1� <br /> TYPE OF SERVICE REQUESTED: �C C 1�� Ci'V UG P. jy TEIVE-D <br /> COMMENTS: 4 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: 1 l ,/�;i 1, EMPLOYEE#: DATE: <br /> ASSIGNED TO: S , lC 1`' r `/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already comple )- SERVICE CODE: '152 PIE t(.)C <br /> Fee Amount: L�[r� Amount Paid Payment Date <br /> Payment Type !` Invoice# Check# �j `�l Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />