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"ERVICE REQUEST <br /> e FACILITY ID# `. SERVICE REQUEST# <br /> Type of Business or Property <br /> 'Sgo0 <br /> OWNER/OPERATOR ` <br /> 'QOC ce- WoolnInJCHECK If BILLING ADDRESSq <br /> 12 <br /> t d <br /> FACILITY NAME <br /> SITE ADDRESS K <br /> `C1 705 Street Number Direction Street Name— city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CIN STATE Zip <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (,20q ) 36 7 - c(,253 0/r/ - l70 7 PP- <br /> PHONE <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) ,xo - a <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CRY 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. <br /> APPLICANT'S SIGNATURE:' ,� DATE: <br /> PROPERTY/BUSINESS OWNED OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11If APPLICANT is not the BiLLINGPARTY,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 enviromnental/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 /> provided to me or my representative. p t,( 1) uJ�4 S T' 10"rs �G- t`/ ex cf— <br /> TYPE OF SERVICE REQUESTED: PAY <br /> COMMENTS: <br /> DEC 2 0 2007 <br /> SAN JOAQUIN COON <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ,r U� EMPLOYEE#: Q 3 DATE: Z 2U w <br /> c V v <br /> ASSIGNED TO: M^1.3 DATE: o <br /> Date Service Completed (if already completed): SERVICE CODE: 1/ L P i E: <br /> Fee Amount: 01 r Amount Paid ` Payment Date (7f 7-v 0 �� <br /> Payment Type Invoice# Check# �'? (o Received By. <br /> EHD 48-02-025 <br /> REVISED 11!17/2003 <br />