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- Eb 0 120219 <br /> 1 <br /> 1 <br /> I <br /> ENVIRONMENTAL HEALTH <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT) .F' ), ft ry- <br /> .. , <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY <br /> /ID # SERVICE REQUEST # <br /> 1w <br /> CAS OT41ION �I S ' � 9 n 0 � <br /> OWNER I OPERATOR CHECK if BILLING ADDRESS ❑ <br /> a±SU5 1UR,A�o <br /> FACILITY NAME �� � � g � ��S <br /> SITE ADDRESS 31 0 45 � Nr14W RQ kD �etG� N � sero <br /> Stree Number Direction I Stroot Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Numher Street Name <br /> CITY STATE. ZIP <br /> PHONE #1 ExT. APN # LAND USE APPLICATION # <br /> 0 <br /> PHONE #2 Exr. SOS DISTRICT LOCATION CODE <br /> ( ) 0 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �1 w d5 CHECK if BILLING ADDRESS ® <br /> BUSINESS NAME PHONE # EXT, <br /> LV. >+IPMu e e , A 9 3 - acl 974 <br /> HOME or MAILING ADDRESS FAX # <br /> :3224 �Glohl _ L ( ) "A <br /> CITY 13 It OSA <br /> STATEaA ZIP 954o5 <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: p�,(;D ��,� DATE: / a 3 • acad <br /> PROPERTY I BUSINESS OWNER 13OPERATOR MANAGER ❑ OTHER AUTHORIZED AGENT I� � KOLtA11.eg A'5;$ I S'TdWr <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION : When applicable, 1 , 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 to me or <br /> my representative. ^�. <br /> TYPE OF SERVICE REQUESTED : ()Sur 1 NSpC1fnON <br /> COMMENTS : <br /> SAN <br /> A 21 <br /> JOAQU//V C <br /> �EACTH�Epq�NTq <br /> ACCEPTED BY: EMPLOYEE M DATE:`IeWi't WD Idea uWa <br /> 'ZZj <br /> ASSIGNED TO : SmootEMPLOYEE M DATE: <br /> Date Service Completed ( if already completed) : SERVICE CODE: PI E: �3Q <br /> Fee Amount. Amount Paid SZ , QCJ Payment Date <br /> Fee Amount+ 62 cT <br /> 2� <br /> Payment Type Invoice # Check # () G� b Re eived By: <br /> EHD 4&02-025 SR FORM (Golden Rod ) <br /> 07/17/08 <br />