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From: 11/03/2008 15,34 #164 P.013/033 <br /> SAN JOAQUI1 COUNTY ENVIRONMENTAL HEALTk EPARTMENT <br /> SERVICE REQUEST <br /> 1 p of Business or Property ACILITY 1D# <br /> ;F1 J4 Dv/4, s Rvlce:REQUEST <br /> OWNER/OPERATOR <br /> t CHECK IfBIU IN�E�� <br /> FAC0.RY NAME <br /> SITE ADDRESS S f 0 ytE�l a 7THCi • /� <br /> StntetNumber ofrection tName <br /> Chn <br /> t C <br /> ode <br /> How orl AKiNo ADDRESS (if Different from Site Addressl <br /> Streal Number / rest a I�Gf <br /> CIT ` ST TE <br /> � zTP o2.3� <br /> PHONE#t XT. APN# LANG USE APPLICATION a <br /> PxomE#2 EXT. SOS DISTRICT <br /> ( ) ` / LocArtoN qotalr, <br /> CONTRACTOR/SERVICE REQUESTOR <br /> IZEauESTOR / �g 11a) 26r���� <br /> (�`�' CHECK if Sfttt G DIIR 5S <br /> BUSINESS NAME s U V` ri 3uL�G �/l ZY-CK3^ <br /> FAX a��lc Exr. <br /> HOME Or MAILING ADDRESS FAi# <br /> CITY ( STATE -P - ZIP 5��-2-7 <br /> IlLING 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 <br /> or activity will be billed to me or my business as identified on this form. <br /> 1 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 /> X APPLICANT'S SIGNATURE: DATTC: �y�3�e <br /> PROPERTY/BUSINESS OWNER19 OPERATOR/MANAG R OTIIER AUTHORIZED AGENT Q <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sigh is required Title <br /> AUTHORIZATION TO REI EASE INFQRMATION: When applicable,I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAR'T'MENT as soon as it is available and at the samem i <br /> provided to me or my representative. t e it Is <br /> TYPE of SERME REWESTED: %i /l <br /> COMMENTS: PAYMENT <br /> RECEIVED <br /> NOV 4 2008 <br /> SAW IGIACIIIING UNTY <br /> ACCEPTED BY: J/_ EMPLOYEE#: VMETNTAL', <br /> ��T'4#i�TTlNiN <br /> ASSIGNED TO: <br /> EMPLOYEE#! DATE; <br /> Date Service Completed (it already completed): SeRwCe CODE: <br /> P11 <br /> Fee Amount: Amount Paid 'a? r Payment Date 'l ,q <br /> Payment Type Invoice# Check# B Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />