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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH LiciPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> MDh;\e k00a c�U',��� -7 �P(, <br /> OWNERIOPERATQQR <br /> JP Vit r CHECK if BILLING ADDRE55O <br /> FACILITY NAME SYY Y� <br /> g;5kro (- L <br /> SITEnnADDRESS {j A r d W cud S��c-k--�c�r 9Sa° S— - <br /> ^`'!!''0( Street Nomber D' Name city Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) {,--}(.p-t4naln C'kl 5+P 2-o3 <br /> 6-715 IN)) Street Number Street Name <br /> CITY STATE ZIP �Sa <br /> (D A CA <br /> PHONE#1 ET' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATON CODE <br /> tsDy> y ov - g y S 3 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Jev.Y"�eC CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT' <br /> HOME Or MAILING ADDRESS ; ^1 FAX <br /> CITY (7ri1/ l^ STATE LIQ- ZIPySa.-a . <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE�Z,,Z, DATE: �125 ) 1-7 <br /> PROPERTY/BUSINESS OWNEROPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 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 i5 available and at the same time It is provided ttgr� <br /> my representative. l/ 1C.`4f <br /> � <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: - J <br /> ? rJ �O <br /> Nes Tr1 eJl� 1,i ���goo�nMFIII <br /> •I,,,,,,, <br /> ACCEPTED BY: EMPLOYEE DATE: <br /> AsSIGNEDTO: EMPLOYEE#: DATE: /—a3-1 <br /> Date Service COmpldt d (if already completed): 1 SERVICE CODE: "'1 PIE: ( " <br /> Fee Amount: Amount Pia¢� oZtS.s� Payment Date <br /> Payment TypeInvoice# Chdck# /7��j Received By: <br /> EHD 48-02-025 , SR FORM(Golden Rod) <br /> 07/17/08 <br />