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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHIEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# ^ SERVICE REQU <br /> -� <br /> OWNER/OPE TOR / <br /> CHECK If BILLING ADDRE55E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Direction +.✓11 !St!-71�reet Name Cotle <br /> HOME or <br /> MAILING ADDRESS (If Differ e fro Site Site A dress) <br /> p Street Number Street Name <br /> CITY V C STATE ZIP 2o2 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ha<) goq �n�4 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUEST- <br /> - C � CHECK If BILLING ADDRESS <br /> BUSINESS NAME / PHONE# EXT. <br /> O <br /> HOME Or MgILING ADDRESS FAX# <br /> /6 / L✓, hXIA6 1 ( ) <br /> CITY STATE ZIP l/C�O <br /> a [ J <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 nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: � DATE:��- 3 0- / <br /> PROPERTY I BUSINESS OWNER OPERATOR/MANAGER � OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILUNG PAR rv,proof of authorization to sign is required Tide <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 timeis provided to me or <br /> my representative. A4lr <br /> TYPE OF SERVICE REQUESTED: ' <br /> COMMENTS: O^t 3 0 <br /> sgN J1- ?018 <br /> Elwj AQUffy C <br /> HfACTH�EPq AL <br /> 1,11147- <br /> ACCEPTED BY: -Muey� c) <br /> EMPLOYEE#: DATE: \ ^1Q <br /> jt <br /> ASSIGNED TO: , A\f � _ EMPLOYEE#: DATE: l�G/'�SI n�D\Z <br /> Date Service Completed (if already Completed): SERVICE CODE: 010 <br /> Fee Amount: -�-1052 pZ) Amount PaidS (52,p6 Payment Date <br /> Payment Type (2a01— Invoice# Check# Received By��/lam <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />