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SAN JOAQUI*UNTY ENVIRONMENTAL HEALT VE PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1 rwb r .0 6fwc&o02.1;7-OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME _ <br /> SITE ADDRESS <br /> Lo� <br /> VkTI Street Number Direction Street Name Cit Zi 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 /> (M) I OP3- 6t) -z-�;;_ <br /> PHONE#2 ExT. BOS DISTRICT LOC TION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> �" CSU <br /> BUSINESS NAMEPHONE /I;_ —XT. <br /> I o (2-04) 1 <br /> HOME or MAILING ADDRES.S FAX# <br /> c <br /> CITY STATE 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 /> 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. r\ <br /> APPLICANT'S SIGNATURE: DATE: Mbq_� ZD1 Iy <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN ER ❑ OTHER AUTHORIZED AGENT I K „ <br /> IfAPPLiCANT is not the BiLLiNGBiLLiNG PARTY 1 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 /> providedto me Or my representative. _ <br /> TYPE OF SERVICE REQUESTED: j�(.S 7— /lam ' f�<l— PAYMENT <br /> COMMENTS: R <br /> MAY 2 8 2010 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTALALTH <br /> DEPAR <br /> HEALTH <br /> ACCEPTED BY: d `f v�C EMPLOYEE#: O 3 Z-4 DATE: -12-r- <br /> ASSIGNED TO: C C- -e f EMPLOYEE#: L�ZZ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: C� P/E: 23 0 <br /> Fee Amount: 3'F.�_fR) Amount Paid 3 4-S (D c Payment Date `--) <br /> Payment Type Invoice# - Check# (f 8'q Received By: A� <br /> EHD 48-02-025 SR FORM(Golden Rod)' <br /> REVISED 11/17/2003 <br />