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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID ERVICE REQUEST# <br /> R�U 7 q <br /> OWNER/OPERATOR _ <br /> \{ O s,--- <br /> J� .v^l 014-1 ^ C /�L� CHECK If BILLING ADDRESS <br /> FACILITY NAME �4 ) LA-`� r 1" C �,�t ' I& "l ✓ l <br /> SITE ADDRESS ^cl co r 1{,�/�/,1 �/� �,f- q C- n t, <br /> street Number pirection `��1r `Name CI ZJi CCaNtle J <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1 -2 ; G 0 <br /> 43�- <br /> Street Number Street Name <br /> CITY !a_ Of-� '1 STATE �./Y ZIP �JI rj 2'(JC <br /> PHONE#1' 1 J`v `/\ EXT, APN# LAND USE APPLICATION# <br /> (.&) <br /> PHONE#2 EXT. BOS DISTRICT001LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,f D MA DQ Il,C <br /> v1 V1 7 y1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> / VZ2 <br /> �I51 -tptp�1 <br /> HOME Or MAILING ADDRESS FAX# <br /> ZL lel <br /> CITY 0- rte 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 application 9.0d th the work to beWormed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards�STATEDE,, laws. �/ {�APPLICANT'S SIGNATURE:( G � �6 QJ c DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT i5 not the BILLING PARTY,proof of authorization to Sign is required Tille <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 a5 Soon as it is available and at the same time it Is provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: I(O 1V>� Iy <br /> COMMENTS: fY 1_ Q(� <br /> VYl .JyS�✓O 22418 <br /> NEIA <br /> o-ly OSE o L,V� <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: C' <br /> Date Service Completed (if already completed): SERVICE CODE PIE: 1�0 <br /> Fee Amount; I C52 L),�) Amount Paid isa. 0,) Payment Date 1 1 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> y 07/17/08 <br /> i� <br />