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• <br />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 />FACILITY NAME <br />L 0- <br />SITE ADDRESS <br />1 Street Number Direction <br />. <br />5 . <br />Street Name <br />0 1 <br />City <br />_ <br />L(C) el 7 S <br />Zip Code <br />Hogor IVIIAILING <br /> <br />DRESS (If Different from Site Address)) <br />I/1 '-/ Street Number Street Name <br />Circ STATE ZIP <br />PHONE #1 Err. <br />F,A) <br />APN # LAND USE APPLICATION # <br />PHONE #2 #2 Ext <br />( ) <br />SOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />• <br />REQUESTOR <br />O.-IN\ VAci PNC -6 C VG 6-‘).- CHECK if BILLING ADDRESS ' <br />BUSINESS NAME <br />L A- 13 ,1/41--vbil, rte,(:_ccA4,_) C- 0 .,- D PHoNE# <br />(2 ,71) 32 .2 -2 <br />EXT. ' <br />HOME or MAILING ADDRESS <br />p, e -')( <br />FAX # <br />CITY Le....0 \ 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 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 an. F DERAL laws. <br />APPLICANT'S SIGNATURE: DATE: / — 3e - 20'4 1 <br />PROPERTY / BUSINESS OWNER 0 OPE / MANAGER la-------;;;THER AUTHORIZED AGENT 0 <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 is provided to me or <br />my representative. <br />TYPE OF SERVICE REQUESTED: P-:-00( \) Q1,-Atc_A-t_ <br />COMMENTS: <br />l(L i V L <br />Z/z (,,, <br />ACCEPTED BY: ,e(A (.6 EMPLOYEE #: DATE: /;a._ -,.Z <br />ASSIGNED TO: u ..'‘) 0 i c EMPLOYEE #: DATE: i p--6 ) L, <br />Date Service Completed' (if already completed): SERVICE CODE: 6 4, / P/E I/O -5 <br />Fee Amount: i .....10,- Amount Paid Payment Date \ -2_, ,b t co <br />Payment Type (\ Invoice # Check # Received By: <br />EHD 48-02-025 <br /> <br />SR FORM (Golden Rod) <br />07/17/08