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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST <br /> c �CA-) S&'6771 <br /> OWNER/OPERATOR <br /> 1�'Arn-h o rn pS Z'n CHECK if BILLING ADDRE <br /> FAciuTvNAME V-1M l,.i C'h Pr^�e'l A ' S-fikd(.(j <br /> SrrE ADDRESS 3i,7 f.3 Lu1 C�`�t ri (-yx-kr S > k�Z�� <br /> Street Number I Direction streett C <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Sweet Number Stre t Name <br /> CITY STATE ZIP <br /> PHONE#1 FXr• APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR i f. <br /> CHECK if BILLING ADORES <br /> BUSINESS NAME Exr. <br /> " <br /> 1 <br /> HOME or MAILING ADDRESS <br /> 307 R <br /> CITY 4COm STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 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,PTATE andITIOWS-cyl <br /> ERALlaws. <br /> r <br /> APPLICANT'S SIGNATURE: DATE: q' 3- n <br /> PROPERTY I BUSINESS OWNEij)!fl OP BATOR I MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 environmentaVsite asse^W information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It is available and at the same time itVC4!��7jTLe Or <br /> my representative. C&NN j�T <br /> TYPE OF SERVICE REQUESTED: (15-%1A W7t1 1t)-\ <br /> COMMENTS: <br /> SqN✓O ®1, <br /> y4 "'Y O N/NCO U <br /> N DFAgR���rY <br /> ACCEPTED BY: No At EMPLOYEE#: ZZ DATE: S Z 1 <br /> ASSIGNED TO: m d' 10'\ EMPLOYEE#: '73 DATE: S ZI r) <br /> Date Service Completed (if already completed): SERVICE CODE: Qb PIE: 1410S <br /> Fee Amount: 19139-OD Amount Paid l D Payment Date S Z <br /> Payment Type V, invoice# Check# v Rece'iv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />