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SAN JOAQUIt'T COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />)() ii(2, .1) tiCle--- <br />FACILITY ID # <br />? 3 y c- <br />SERVICE REQUEST #i <br />5 66---) I 7 y <br />OWNER I OPERATOR <br />A- N D 1?-6-v ) L-/I-Sk0111C7=/ CHECK if BILLING ADDRESS <br />FACILITY NAME rx e&uski. <br />SITE ADDRES <br />.7S Street Number Direction LC- (5 Street 1me ci 3 t 1 d <br /> <br /> . - <br />5ic - Citv x-5-,5771 Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) <br />663 3PD A L/Cf- Street Number Street Name <br />CITY 5 . S3tTE <br />PHONE #1 EXT. <br />( '1/(0) S 0 L —0677Y <br />APN # LAND USE APPLICATION # <br />PHONE 1/2 EXT. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE <br />REQUESTOR <br />_ <br />CHECK if BILLING ADDRESS <br />BUSINESS NAME ,_--- —1?-_ , PHONE # <br />( ) <br />EXT. <br />HOME or MAILING ADDRESS FAX # <br />( ) <br />CITY STATE 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 />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, STAT FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br /> <br />DATE: <br /> <br />PROPERTY / BUSINESS OWNER OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT 0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <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 is available and at the same time it is provided to me Of <br />my representative. <br />TYPE OF SERVICE REQUESTED: 1/27 • <br />COMMENTS: PAYMENT <br />M 6oct_ REcovED <br />iuu 01 6 <br />thN COUN" <br />AN JOAQ AL ENVI <br />7 <br />S FOMENT <br />ACCEPTED By: my: EMPLOYEE #: HEALTH CI qA6r E : <br />ASSIGNED TO: )46141 Ar7ti s:2__ em 7„ .2_ EMPLOYEE #: DATE: <br />Date Service CompletA (if already completed): SERVICE CODE: O6/ P /E: /03 <br />Fee Amount: / '(-) C TO <br />t ' ,-) <br />Amount Paid 4 [30 , vo Payment Date —711 1 l(p <br />Payment Type cfs)s,h Invoice # Check # Received By/ <br />Title <br />EHD 48-02-025 <br />07/17/08 <br />SR FORM (Golden Rod)