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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -)b:X') )i L'(P'J- <br /> OWNER/OPERATOR <br /> /��� � �J M C�,�,�l✓l CHECK If BILLING ADDRESS <br /> FACILITY NAME p art <br /> SITE ADDRESS �� ce4,Ntcco J , ' _ I i <br /> Street Number Direction Street Name 1-Ci� Zi Code U <br /> HOME Or MAILING ADDRESS (If Different from Site Address) L-1- /, b (\ <br /> M Q 0d <br /> Lt <br /> Street Number Street Name 1` <br /> l CITY STATE ZIP <br /> Livi� ��� <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. 6 [!AT!ON <br /> 05 DISTRICT CGDE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> V(j CHECK If BILLING ADDRESS <br /> ,,—BUSINESS NAME { PHONE# ExT. <br /> Vb^c �Q� �, 016) x-52 - ?02Z <br /> HOME O MAILING ADDRESS F <br /> CITY FA(t pC—, N 10 STATE /A 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 F ERAL I S. <br /> APPLICANT'S SIGNATUFfE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ AGER ❑ OTHER AUTHORIZED AGENT ❑ <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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It IS provided t0 me Or <br /> my representative. \\ �jAd <br /> TYPE OF SERVICE REQUESTED: a�L l(iti'j/l RE IV,` <br /> COMMENTS: <br /> SANTO 51p,S <br /> 0MCTOawv Y <br /> Q�rME <br /> ACCEPTED B ' - EMPLOYEE M DATE: S <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (ifalready pleted): SERVICE CODE: S L 3 PlE: K <br /> +r <br /> Fee Amount: y( Amount Paid Payment Date <br /> Payment Type „ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />