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i <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH OEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 3-71-:K T-s t x�0S� <br /> er OWNER OPERATOR <br /> ^ ^ / CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS r ) <br /> G[—/ 4n, <br /> Street Number Direction /` treet Na �C� / e O <br /> HOME or MAILIN GA DDRESS_J1f Different from Site Ad ress) <br /> J Street Number Street Name <br /> CITY GD ,,/ STATE C47. <br /> zip <br /> PHONE#1) �� �/ F T• APN#/ LAND USE APPLICATION# <br /> '1Gi✓yQr7 lJ r�J3�}-- S <br /> PHONE#2 EXT. BOS DISTRICT LOCATJON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME /D A % / / �^, PHONE# �� xT <br /> HOME Or MAILING ADDRESS � O � �_ •- Ff�� <br /> CITY STATE KJ zip g�0� <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 <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 he work t?,be performed ill be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and F RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: rx, <br /> PROPERTY/BUSINESS O P TOR/ NAGER ❑ OTHER AU ORIZED AGENT❑ <br /> If APPLICANT is no the ILLING PAR proof of aut orizadon o sign is required Title <br /> AUTHORIZATION RELEASE INFORM ION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release f any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRON NTAL 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: rJ Cc—des CZ <br /> COMMENTS: RECEIVED <br /> MAY 13 20111 <br /> SAN JOAQUINCO TY <br /> HETI{DEPARI�ENWT NT <br /> ACCEPTED BY: l V I EMPLOYEE#: _,2 -6 DATE: s- /3 1✓ <br /> ASSIGNED TO: �i� 1¢ I EMPLOYEE#: l f�Z DATE: S '- LQ <br /> Date Service Completed (if already completed): SERVICE CODE: (q 2 P/E: C y <br /> Fee Amount: L • �� Amount Paid - 3 �0 Payment Date S(3 <br /> Payment Type Invoice# Check# �' Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />