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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G , - • ,s96o-74--7 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> ( � <br /> FA NAME 4f CA �� <br /> SITE AD REST S C/ Po W ce *( 5 �O�f40, _ <br /> Street Number Direction Street Name CI Zip Code <br /> HOME or FAILING ADDRE�SS (If Different from Site Address) <br /> `L �,�j0y � - i Street Number C-; Street Name <br /> CITY Q STATE ZIP <br /> (C <br /> Jca fnV `7 (/ <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> R;:IQUESTOR <br /> CHECK If BILLING ADDRESS <br /> O Q • C Z <br /> BU ES NAMES CO' P <br /> HOME or MAILI ADDRESS FAX# <br /> itCy <br /> CITY T p STATE ZIPLA <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 laws. # <br /> APPLICANT'S SIGNATURE: _ DATE: 65- 6 <br /> PROPERTY I BUSINESS OWNER❑ ( PERATOR/MANAGER ❑ 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 assessrh4byVINt—b <br /> IE <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the same time It ISOVImy representative. I" - <br /> TYPE OF SERVICE REQUESTED: VV-OA .QiY` de '-W CAM MAY U 2 201 <br /> COMMENTS: SAN JOAUL11N COL NTY <br /> EN'JIHOMENTA <br /> DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: •z <br /> ASSIGNED T0: dQ�{ �� EMPLOYEE#: DATE: '—L-/2/1 <br /> Date Service Completed (if already completed): SERVICE CODE: Jt;C-C> � P IE: ((p 03 <br /> Fee Amount: (3c c2 Amount Paid 3 /� c? rent Date <br /> Payment Type ��S Invoice# Check# Received By 7 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />