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SAN JOAQUOCOUNTY ENVIRONMENTAL HEALTHOEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �a�line <br /> a5ff-ntine 561lbv ay <br /> OWNER/OPERATOR /'�., <br /> hei it CD' CHECK If BILLING ADDRESS� <br /> FACI'2114LITYNAMEI��I ��� ..JI eII & Mlht Mgt <br /> SITE ADDRESS �53��0 <br /> 37Z5 Street Number Direction Stre t ame TraceC -TZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#T EXT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 'Z.7i0ja V�/_. <br /> Zn i r1 D CHECK If BILLING ADDRESS <br /> EXT. <br /> BUSINESS NAME -jt-.ante[� PHONE 707 7�o y�l�bb `O-7 <br /> kfiaf <br /> MAILING ADDRESS FAX# <br /> X 137 W. 06020-011 l lol )7G5-a 9 o8 <br /> 4854BCITY }7et21Uma STATE G,& ZIP 94q54- <br /> BILLING <br /> ILLING 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 <br /> or 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 and FEDERAL laws. 1 <br /> APPLICANT'S SIGNATURE: -:^^^� an k2'- ,aw of &Ie {u t21AC 12A14 DATE: G G roJB�(' ' <br /> PROPERTY/BUSINESS OWNER❑ %ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT /�1RG`1 A61y►G 1171I►t. <br /> —v <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 <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: j2AYNAENT <br /> COMMENTS: i�ecc–N <br /> SUN 19 2008 JUN 1 9 2008 <br /> OAp,UIN�ouNn ENVIRONMENT HEALTH <br /> SAN J <br /> ENS►RONME TME T PERMIT/SERVICES <br /> ACCEPTED BY: / EMPLO DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already co pleted): SERVICE CODE: P/E: <br /> Fee Amount: .' Amount Paid � Payment 6ate <br /> Payment Type Invoice# Check geceiv6d Byl <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />