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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH UEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#'I <br /> OWNER/OPERATOR <br /> �OIK LI_SGV C- 0 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 11 �, ✓ 5, l UVtto� S-c� S l aSLp S <br /> Street Number I Direction Street Name IN Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) D �„� dui <br /> ( j (� Sulnnt� Si <br /> Street Number Street Name <br /> CITY t/ _ STATE Zip <br /> / 5 l f Z L2 5, <br /> PHONE#1 EXT. APIA# I LAND USE APPLICATION# <br /> S2c54 ` � 33q b <br /> PHONE#2 ExT. SOS DISTRICT <br /> i . > _� 93 3 0 LOCATION ODE <br /> a � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> HOME of MAILING ADDRESS FAx# <br /> ( ) <br /> CITY STATE ZIP <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 buska',identif!ed on this form. <br /> I also certify that I have prepared thiand that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, StandardsEDERAL laws. <br /> APPLICANT'S SIGNATURE. — ,L(i m S DATE:�tC / s <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 /> 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: `—� �, Z <br /> NOT <br /> COMMENTS: <br /> z <l 1= Z RECEI ED <br /> FEB 1. 2015 . <br /> So JOAOUI COUNTI <br /> 1�'- AL <br /> 4, NVIHO A MENS <br /> ACCEPTED BY: t�- 1.D. , '�wV <br /> EMPLOYEE DATE: /-� <br /> ASSIGNED TO: �.♦ l V EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: cp� d PIE: 16o--2' <br /> Fee Amount: t 30 Amount Paid � '7 f^ Payment Date I t <br /> Payment Type AInvoice# Check# Received By: <br /> EHD 4802-025 - SR FORM (Golden Rod) <br /> 07/17/08 <br />