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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# cSIB M77-.A/9- <br /> ERRVIICEREQUEST## <br /> TUoG <br /> Hor C-AdZZ J77-. / / <br /> OWNER I OPERATOR <br /> '^� L A U� t-- CHECK If BILLING ADDRESS <br /> FACILITY NAME. 1 <br /> hp <br /> SITE ADDRESS 1 rJ^ <br /> $0J9'z Street Number DI.cUonSirCeet Nama f'a ��1C�a� Zip C. <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 4900 N, VA W '�9 Street Number Street Name <br /> CITY STATE ZIP <br /> S1-oc100;.S Ln gSaT <br /> PHONE#t EXT' APN# LAND USE APPLICATION# <br /> (X01 5L)-i tarso <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR. <br /> RE`QUUEESTOR <br /> {�CA,4 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> 14'caaQAL- (a-15Sbl -?�F3 <br /> HOME Or MAILING ADDRESS FAX# <br /> CITY s c,c OC (N STATE C,n ZIP �MqAI 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, E aridFEpERAL laws. <br /> APPLICANT'S SIGNATUREi DATE: �S I <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER EJ OTHER AUTHORIZED AGENT <br /> IT APPLICA is 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon a5 it IS available and at the Same lime It IS-provided to me or <br /> my representative. a(w'�1� Y <br /> TYPE OF SERVICE REQUESTED: �.C(� ���✓����'4� <br /> COMMENTS: ^pp L r� 't017 <br /> SAEtJjV1 RON(ME COUNTY A <br /> HEALTH DEPARTNiF%T <br /> ACCEPTED BY: aAm <br /> =EMPLOYEE#: DATE: <br /> ASSIGNED TO: in I I EMPLOYEE#; DATE: - _ /-7 <br /> Date Service Completed (If alreadycomplefed): SERVICE CODE: PIE: J4�0a <br /> Fee Amount: I 1X7 Amount Paid 13 Payment Date t� _ _ ' '7 <br /> Payment Type C Invoice# Check# L,a, 3 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />