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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> /4 OD z&3(pS SQL 1706'�2y'4 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME M OG, rloo r rl <br /> SITE ADDRESS Ca,l;(��✓ita ':4 <br /> Street Number I Direction LCAM�US1reet Name -'I I'1vcity ZipCode <br /> HOME or MAILING ADDRESS (If Different from$Iite Addres$)'A`'�/,/ <br /> Street Number Street Name <br /> CITY STAT EA <br /> ZIP Z( (� <br /> PHQ T `d 3 0— 09 D LI APN# LAND USE APPLICATION# <br /> PHONIERlV Exr. BIDS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> �'A a�^ O�i ��� CHECK if BILLING ADDRESS <br /> BUSINESS NAME 1/` I , PH NE <br /> W. OGI�1O� U— CogO� <br /> HOME Or MAILING ADDRESSQ ^ Ct,V-1 P& <br /> ` FAX# <br /> CITY STATE OA ZIP Oj l5Z <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 <br /> or 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 STATE a E la <br /> APPLICANT'S SIGNATURE: r / r,1 1 <br /> v "`� DATE: V 5 Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGEROTHER AUTHORIZED AGENT El <br /> If APPLICANT i5 n01 the BlLLINGPAKTY proof of authorization t0 Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. p <br /> qwillp <br /> TYPE OF SERVICE REQUESTED: C V Q 1t cke Wve&V`- '� CNTRE <br /> COMMENTS: <br /> y 0JOA5 pppl <br /> ORO UI N COON <br /> H�ITH p7-1 <br /> g ARTM NT <br /> ACCEPTED BY: ll EMPLOYEE#: DATE: -5 <br /> 21 <br /> ASSIGNED TO: Y Y l 1' EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0(0 P 1 E: <br /> Fee Amount: 4� I(:�?2_ Amount Paid a.— Payment Date a ,5 a,( <br /> Payment Type J Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />