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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTEPARTMENT <br /> SERVICE REQUEST <br /> TygeittuTAAowroperty FACILITY ID# �?�S�cERVIC(E 7(Q:rUE7S #j: F' r�c.0 r� 2 a GJ koc U c'S <br /> OWNER OPERATOR <br /> CHECK If BILLING ADDRESS <br /> /7 <br /> FACILITY NAME <br /> SITE ADDRESS s.oFr /n..w,r7✓�� a/ <br /> S -2 S' Y StreeTNurhber Direction Street Name City Zip 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 /> ( � i�I3 — �3c�— ►1 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRE S <br /> BUSINESS NAME PHONE# Ex <br /> HOME or MAI?LIING ADDRESS FAX# <br /> CITY STATE ZIP �S <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project speVA lentified <br /> c ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> siness <br /> activity will be billed to me or my buon this form. <br /> also certify that I have prepared this a lic tion and that the rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, SAT and FEO L law <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ 'PE RAT IR MANAG ❑ OTHER AUTHORIZED AGENT J� C�S/l�tZ/� L� T% <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required' 1 Tire V <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 /> to 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. <br /> TYPE OF SERVICE REQUESTED: ✓`l /V i( r/ <br /> COMMENTS: MENT <br /> RECEIVED <br /> USH SEP 2 4 20113 RUSH <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ACCEPTED BY: EMPLOYEE#: n l �1 O DATE: Z / <br /> ASSIGNED TO: ,v' 19(f Ck EMPLOYEE#: i / ; DATE: <br /> Date Service Complete (if already completed): SERVICE CODE: 034, PIE: -2 <br /> Fee Amount: Amount Paid �� Payment Date 91A,1113 <br /> Payment Type Invoice# Check# 13 Oe-k Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />