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SAN JOAQtJIIN COUNTY ENVIRONMENTAL HEALTH L,PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />G� CHECK if BILLING AGORE55E] <br />BUSINESS NAMEPHONE# <br />FACILITY ID # <br />E%T. <br />.POq I Z' -j7 - &, d <br />SERVICE REQUEST If <br />OWNER / OPERATOR <br />FAX# <br />CHECK ((BILLING ADDRESS El <br />FACILITY NAME <br />a. <br />a r+ <br />DATE: <br />ADDRESS <br />SITE/ nA <br />C0 V � Street Number <br />Dbectlon <br />~f— � <br />O LauStreet Name tr <br />L <br />�CI <br />rj.c ryl� <br />Zia Code <br />HOME Or MAILING ADDRESS (If Different from <br />Site Address) <br />Street Number <br />PIE: <br />Street Name <br />CITY <br />Payment Date 3 --I�e IS <br />STATE ZIP <br />PHONE #t <br />I ) <br />En. <br />Received By: <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 <br />t ) <br />EZT. <br />BOB DISTRICT <br />LOCATION CODE <br />CONTRACTOR/ SERVICE REQUESTOR <br />REQUESTO& t S <br />(1 <br />G� CHECK if BILLING AGORE55E] <br />BUSINESS NAMEPHONE# <br />tAA u ow, <br />E%T. <br />.POq I Z' -j7 - &, d <br />HOME Or MAILINGADDRESS <br />.11 <br />No <br />FAX# <br />I AIN [lel <br />� <br />CITY T9 <br />STATE ZIP Gi 3 a <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, ST E and FEDERAL IaWS. <br />APPLICANT'S SIGNATURE: ;T Lyv DATE: <br />y LL3�-26 <br />PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHERAUTHORIZED AGENT Ll��'jyy�/til -%O/ <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 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 t0 me or <br />my representative. oval <br />TYPE OF SERVICE REQUESTED: <br />PPLI VIII <br />D <br />COMMENTS: n <br />I,} <br />p (0.'y FG' <br />SANEI vlvm HOM <br />1 <br />1 <br />OEpA <br />HATH <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: <br />Date Service Completed (If already completed): <br />SERVICE CODE: ri »2— <br />PIE: <br />Fee Amount: �Luf) . <br />Amount PaidO <br />Payment Date 3 --I�e IS <br />Payment Type CIA,, 2 <br />Invoice# <br />Check# r1%6L,I <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />