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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7. X-CC T �,Q CIA 06742---19-) <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> 6�5 (L C' c� CC57 C <br /> FACILITY NAME <br /> EL Slv� ��orr o� SE <br /> SITE ADDRESS I'� ` "k S, V03 t00 ST, Sro c„tr C-7-) <br /> Street Number Directlon Street Name cityZI Cotle <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> 22 k ©�IrN CU\ J7 ; Street Number Street Name <br /> CITY -� STATE ZIP <br /> PHONE#1 y L �q l�r EXT APN 11 /jam LAND USE APPLICATION# <br /> (2CN � r— � <br /> \ J /J Yip' l <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> C r N C GQ- T rn CHECK If BILLING ADDRESS <br /> BUSINESS NAME C.� Y= PHONE# EXT' <br /> LL S/ vJaL EPSP 2 g93 - 5-R8C <br /> HOME.Or MAILING ADDRESS ,�y FAx# <br /> 221 Qo71T Cy ST, /d2? l ) <br /> CITY S CC.0 1-(5-13 <br /> STATE /�e ZIP Qs Za <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: '/�?-r(L,-'i DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time ItCSwfOXided to me or <br /> my representative. � �"NiF., <br /> TYPE OF SERVICE REQUESTED: (A .��' ('� rt V EQ <br /> COMMENTS: f� 9?0�6` <br /> O e uJ ow 1 t�c N ENV AO41E COUNTI, <br /> EALTfI OCp ENTAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: _ / <br /> ASSIGNED TO: EMPLOYEE DATE: lam `/ <br /> Date Service Completed (if already completed): r7 SERVICE CODE: 610 1 /P/E: 1 15,03 <br /> Fee Amount: \ (�' Amount Paid-r3q,)D Payment Date ' q <br /> Payment Type j Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />