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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> 1A/,9,9Ar 5Alyollu <br /> FACILITY NAME -7— <br /> SITE ADDRESS 3 -77 s t-n o c�Al TA Id 1q t2V SE /'K W, / /kAc-,y <br /> Street Number Direction Street NameCit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 3 7 _5T- Du'K . M <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> -722AC,k4 Cil 3 0 <br /> PHONE#1 EXT. AN# LAND USE APPLICATION# <br /> �o ) 3 - �i7 opZ0 - p- — p0 o� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> E. CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> cow/ r� o of - 14 s <br /> HOME or MAILING AQDRESS FAX# <br /> CITY n C STATE r�( 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 business as identified on this form. <br /> also certify that I have prepared this 5Kplication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, T E and F E AL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATO /MANAGER ❑ OTHER AUTHORIZED AGENT 07 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirie <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 It IS provided t0 me or <br /> my representative. P <br /> TYPE OF SERVICE REQUESTED: <Ag rA CEI PPP <br /> COMMENTS: 4 �® <br /> %'/0 ?0,9 <br /> h' �N►�iR Q�iN c <br /> �ryoEpgR MIJ � <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service CcInpleted (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Pal Payment Date <br /> Payment Type /y Invoice# Check# Recei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />