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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property a 00FA�LITY�# s SERVICE REQUEST <br /> OWNER/ PERATOR V` r7t t, ,�a rn��ECKifBI LI <br /> CHECK If BILLING ADDRESS/ <br /> FACILITY NAME C I J6 _rnonn s '� y-�� _t_.� <br /> SITE ADDRESS /1n�1�^I f(i�'� �I Vf'� o I � ls�. (� C IvCi��On C� ._ <br /> Street Number Direction Street Name C� CI Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ")o .0fe- Street Number Street Name <br /> CITY 1Q'+-0 C I< tol l STATECA ZIP <br /> PHONE#t ExT. APN# LAND USE APPLICATION# y[,v <br /> 001) �PLI( 0- h <br /> PHONE 42 ExT BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR <br /> /—'� <br /> /t V <br /> .cc, I O CHECK if BILLING ADDRESS <br /> BUSINESS NAME P NE# EXT. <br /> 1-Os r (- PQr f "� Qy(n 0 <br /> HOME Or MAILING ADDRESSr�^^ f rs � (s� (A%# ) <br /> CITY C LO a(,I J STATE CA <br /> ZIP q5-2)5 5no5 <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 perlbrmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards STATE and FEDE L laws. <br /> APPLICANT'S SIGNATUR •• — z -- DATE: //1^1 <br /> fig <br /> PROPERTY I BUSINESS OWNER rf.a OPERATOR/MAN GER ❑ O NER AUTHORIZED AGENT ❑��'IF,I'' <br /> If APPLICANT IS not the BILLING PARTY,Proof of alit orizati0n 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 Alarovided to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: C <br /> COMMENTS: Pp <br /> '1 12 <br /> FN✓C,gQVI 209 <br /> Ro C <br /> NFA //CF�N III <br /> 'Y <br /> FNT <br /> ACCEPTED BY: Ike EMPLOYEE#: I�/v DATE: (J_ <br /> ASSIGNED TO: 7 A EMPLOYEE#: V� DATE: 1 n 1 <br /> Date Service Completed (if already Completed): SERVICE CODE: � PI E: ) <br /> Fee Amount: 19- Amount Paf le-1� v Payment Date ` <br /> Payment Type V;-5 Invoice# Check# c7e-37r2I0,-, Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />