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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Toad TNcl'— G - o otuNv <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> G— T 0 Ci :Vl <br /> SITE ADDRESS -1'30 S �� t (� X1520} <br /> Street Number Direction Stre¢t Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITYr- STAAT�/E� ZIP <br /> TWl [spy <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (?A) (D -(cOZS <br /> PHONE#2 EXT. BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �r�,�rr � �VV, �� <br /> �Vl/A nJGI.✓✓71 CHECK If BILLING ADDRESS <br /> BUSINESS NAME �•••�, y n -YA I O 1&iV <br /> HOME or MAILING ADDRESS UOS .C,0YVr Lc L. (t„ FAx# <br /> V r> i..V �9� <br /> CITY O\.. \ STATE ZIP c- <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 applicatio and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STA a EDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: —IQ - lq <br /> PROPERTY/BUSINESS OWNER ERA / ANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING RTY,proof of authorization to sign is required 7'irte <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 asgIr��s/gL �ca�rrT�ytion <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 it is available and at the Same time IYi �Kyl71e Or <br /> my representative. 1r q <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: jUN 19 20i9 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: .M,t.A rl.n EMPLOYEE#: DATE: <br /> ASSIGNED TO: (V t 1-llV�t'/'V U� � EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: IE: WQ <br /> Fee Amount: . 15'� Amount Paid L 5� �„ Payment Date / <br /> Payment Type Invoice# Check# '� 2 ft 6 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />