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SAN JOAQUIN -)LINTY ENVIRONMENTAL HEALTH DE RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ides Buz Iv t�kR <br /> - 0 0!s 3�-(o Sid DO-7(p 5 3I <br /> OWNER/OPERATOR � CHECK if BILLING ADDRESS❑ <br /> 1 J-t "T(y (ppl J Z IAC 1� <br /> FACILITY NAME C w t I I, <br /> 4J <br /> SITE ADDRESS ?—)s At I rJ ,Z i L �tC�t< r ni , S Z r Z <br /> Street Number I Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> L j zJ t'-�( V T R C--J?t -N Street Number ( Street Name <br /> CITY STATE ZIP <br /> cA (11 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (`z"�) ' 2 - 66ci( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> (A-A o M1,k �12� CHECK if BILLING ADDRESS <br /> Ll.' <br /> BUSINESS NAME J PHONE# ExT. <br /> (LU6 1 k'k �� 7-2 'i^-66G <br /> HOME or MAILING ADDRESS _ FAX# <br /> CITY i STATE C j ZIP 95 Z <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 /> 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 la s. <br /> I \ <br /> APPLICANT'S SIGNATURE: �+ DATE: <br /> PROPERTY/BUSINESS OWNER\C OPERATOR/MANAGER I OTHER AUTHORIZED AGENT ❑ <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 above <br /> site address, hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time it is provided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: aoj C l o <br /> COMMENTS: A <br /> A4N <br /> SAN 30 v a <br /> �ogAnA—o 20 <br /> ACCEPTED BY: Oth EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: !� MF <br /> Date Service Completed (if already completed): SERVICE CODE: /p ' P/E: u� <br /> Fee Amount: I PJ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />