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SAN .IOAQ 1 COUNTY ENVIRONMENTAL HEALTH UrPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> bol CA )2 klljwjll-�� <br /> FACILITY NAME <br /> 'Peaowce <br /> r.SIT ADDRESr'gy' _ <br /> Z Direction Street Nam. Ci Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH0NNEE##1 pEZT. APN# LAND USE APPLICATION# <br /> 'c f 3 <br /> ( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> QDESTDB <br /> �>� CHECK If BILLING ADDRE <br /> BUSINESS NAME) PHONE# En <br /> I3 O <br /> HOME or MAILING ADDRESS FAX# <br /> \ <br /> �Vl �L 3 ( ) <br /> CITY STATE on ZIP S-�� <br /> In <br /> BILLING ACK WLEDGEMENT: 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: g �� P7 DATE: I L/ <br /> PROPERTY I BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY,proof Of authorization f0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the a1, <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment infor o Y <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it Is available and at the same time It Is provided t I �/Vr <br /> my representative. ), / <br /> TYPE OF SERVICE REQUESTED: 4 /Gly C ��'� S Zt / O <br /> COMMENTS: H��� � O�0 <br /> LIGE//C( ��� �jL HOFaAR 7,44 <br /> q< <br /> MFT1'T <br /> ACCEPTED BY: I EMPLOYEE#: DATE: '/2 <br /> 1-7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: /.�. <br /> Date Service Complete (if already completed): SERVICE CODE: PIE: I 03 <br /> Fee Amount: I Amount Paid ` ,,00 Payment Date <br /> Payment Type Invoice# Check It Received Byes <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />