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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Busines or Property FACILITY ID# SERVICE REQUEST# <br /> o u�)2-S 5R 0077 D&S- <br /> OWNERtOPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACIDTV NAME <br /> 1 e- w <br /> SITE ADDRESS �cJ!'�� 1A,� y� <br /> Street Number DIr Ion " (: tiCy '•`�$tr t Nama CI ZI Code ` <br /> HOME Or MAILIN ADpRESS If Different from Site Address) <br /> e3 <br /> f G i 133 Street Number Street Name <br /> CITY STATE ZIP <br /> Vhe Car 6 Q3q <br /> PHONE#1 Exr. APN# LAND USE APPLICATION# <br /> k ) 3 52 <br /> PHONE#2 E BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SEIIRVICE REQUESTOR <br /> REQUESTOR l <br /> '(/l CHECK If BILLING ADDRESS <br /> BUSINESS NAMEI/�1 Aq- O PHONE# Enr. <br /> SCP l G�C <br /> If <br /> HOME Or MAILIN ADDRES 11 FAX# <br /> o I G�N21t ( ) <br /> CITY SATE ZIP Ct <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 lh bfh worN b erfonned will be done in accordance with all SAN JOAQUIN , <br /> COUNTY Ordinance Codes, Standards,STATE and FE ePAL I <br /> APPLICANT'S SIGNATURE: DATE: <br /> T— <br /> PROPERTY/BUSINESS OWNER❑ <br /> OPE TOR/ NAG HER AUTHORIZED AGENT ❑ ' <br /> If APPLICANT Is not the BILLING P ro0 orization 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 as it is available and at the same time it is provided to me Or <br /> my representative. Q/��/p� <br /> TYPE OF SERVICE REQUESTED: e 1 � U PAYMENT <br /> COMMENTS: RECEIVLU <br /> I v 0 M'Lw MAR 11 2057 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTALARTMENT <br /> WrAITA P <br /> ACCEPTED BY: M EMPLOYEEM DATE: r 2'"] -7 ,. <br /> ASSIGNED TO: O, rn/1 1 I EMPLOYEE DATE: ,2 ; 7 /-7 <br /> Date Service Completed (dal com eted): SERVICE CODE: S66('e PIE: G <br /> Fee Amount: 1 -3 01 Amount Paid 13 (� ' C7 C� Payment Date 3 <br /> Payment Type Co Invoice# Check# Received By(.� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />