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SAN JOAQUIPCOUNTY ENVIRONMENTAL HEALTH MARTIMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> (2-- �2Qd I n lin Biba-7a `I <br /> OWNER/OPERATOR <br /> - <br /> rSGINIHECKIfBILLINGADDRESS <br /> � <br /> FACILITY NAME ������ ► J ���� �/�� <br /> SITE ADDRESS Itl�/G'�rDirectioTQC'Ln <br /> i'J� ` 9Cod4/ig <br /> 11-753 1 Street Number 1CStreet Name CI VZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P. O• P Street Number Street Name <br /> CITY STATE zip <br /> L oct co <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> (!2 a)) ; c7v 31y- <br /> 2 Pr+- 130(0-z, a <br /> PHONE#2EXT• <br /> �) gt o l CJ rC, ovS DISTRICT LOCATION CODE <br /> / `I CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR s14ME <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 WS. / <br /> APPLICANT'S SIGNATURE: n DATE: CO !/ I/ <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ O(c7Y L,Q-A2- <br /> /f APPLICANT fs 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 t0 meAr <br /> my representative. , L� <br /> TYPE OF SERVICE REQUESTED: ��jf I W� �� ` . ^^1I♦ s�Nr <br /> COMMENTS: 7 �O <br /> h�N��4 H <br /> CTjy U�� qr�NAY <br /> MFNT <br /> ACCEPTED BY: /� r�� ua /Z 3-;-`t- EMPLOYEE#: DATE: 61� <br /> ASSIGNED TO: lUjp / G, /~/, EMPLOYEE#: -�ed jZ.,) DATE: ell 2111- <br /> Date Service Completed (if already Completed): !�✓ SERVICE CODE: �� :2 P(E: y O Z <br /> Fee Amount: 22-6 o , 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 />