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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 I OPERATOR CHECK if BILLING ADDRES <br /> FACILITY NAME <br /> v-vim <br /> SITE ADDRESS 11K1?— P�� fnC, a 3_3 <br /> r Street Number Di ection Street Name CIT` 7 �i PCode <br /> HOME Or MAILIF's ADDRESS (If Different from Site Address) <br /> i r18 ' C. TV'4 �i Street Number IN Street Name <br /> CITY /J /� STATE ZIP 2` <br /> t�LC-64 C� C� R i (� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> i Lf / 3(-% <br /> PHONE#2 EXT. SUS DISTRICT LOCATION CODE <br /> CONTRACTOR SERN710E RF-QUESTQR <br /> REQUESTOR �� ` <br /> CHECK If BILLIIJG ADDRESS irk <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# J <br /> CITY C STATE CA <br /> /� ZIP <br /> BILLING ACKNOWLEDGEMENT: E, the undersigned property or business owner, operator r7or 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 t at tele w to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, ATE a FED AL laws. <br /> !iF°F''LIl.b11Y I'j JIGIVF1 T l.itCt: \ DATE' <br /> PROPERTY/BUSINESS OWNER❑ OPER TOR/MANAGER ❑ OTHER/AUTHORIZED AGENT ❑ G W �/��� <br /> If APPLICANT Is not the BILLING PAR TY,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 proVlPAtQ me Or <br /> my representative. Y M <br /> TYPE OF SERVICE REQUESTED: Iy <br /> D <br /> COMMENTS: ( 8 �� <br /> Ve CA-C- SAN <br /> HIV <br /> EL�H DEp ECA N)y <br /> pw Nr <br /> ARr <br /> ACCEPTED BY: EMPLOYEE#: DATE: I <br /> ASSIGNED TO: e�Y�h� r15 EMPLOYEE#: DATE: ' <br /> Date Service Completed (if already completed): SERVICE CODE: PI E: �(CO <br /> Fee Amount: 9 �� w Amount Pa - Rt�>/)! ? Payment Date 7,;� <br /> Payment Type i% Invoice# Check# Received By:r <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />