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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# -SERVICE V000-�-lv <br /> P,;Q EST# <br /> OWNER/OPERATOR 1f^ <br /> CHECK if BILLING ADDRESS El <br /> FACILITY NAME vL of C(-) i I_Cron C-T—r LW C- l� l CL- <br /> SITE ADDRESS F yam- 'e P-0, 0- 1. 23�L <br /> Street Number I Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 4<; Air j cn fi j� I V c4,, <br /> Street Number 1 Street Name <br /> CITY l tl:L1 L S �� STATE ZIP <br /> ( Lo- L� y 4 0 1�a <br /> PHONE#1 7 EXT. APN# LAND USE APPLICATION# <br /> S `� 7 �L <br /> C)2_c') <br /> PHONE ill EXT. \ BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR (� '/ <br /> C w l In F�') -r W i vi11 CV CHECK If BILLING ADDRESS <br /> BUSINESS NAME (� U,0 5• 2 C PHONE# ' f E.T. <br /> HOME or MAILING ADDRESS � Q FAX# <br /> CITY S �C�t�t �' Y n",-C C S C L) STATE ham) ZIP 0 L, <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 n DERAIL laws. `� `, <br /> APPLICANT'S SIGNATURE: DATE: 14 2 4 <br /> PROPERTY/BUSINESS OWNER❑ OP ATOR/MANAGER ❑ OTHEKAUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 assessme//��+I formation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time it IS pr i or <br /> my representative. , <br /> TYPE OF SERVICE REQUESTED: �� �j r� _� F �' <br /> COMMENTS: <br /> H� RO�/HC TyO A,q�H q�N� <br /> MFNT <br /> ACCEPTED BY: /1G/11,t q EMPLOYEE#: DATE: / <br /> ASSIGNED TO: ��J / EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: PIE: z <br /> Fee Amount: /+C� Amount Paid �7 /�7) Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />