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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S9--0oI(V-�92) <br /> OWNER/ y-PERATO � / ' <br /> V CHECK if BILLING ADDRESS El <br /> FACILITY NAME �/� �} I `/ <br /> t / / L �/ /� /� <br /> SITE ADDRESS r I J C vi -1 <r ✓ I V (c f-,)n `I Z 7 <br /> Ireoet <br /> tt Number I Direction Street Name CI Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR �I <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME 11 � p PHONE(ul I 17'+ �� � <br /> EXT <br /> HOME or MAILING ADDRESS 1 l• FAX# <br /> �- <br /> L-I Y1 C V1C ( > <br /> CITY ro uz— i--b ', STATE CZIP <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 /> 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: y M" Ilud DATE:. A <br /> 2 nn / fLj1� r' <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHE UTHORIZED AGENT ' C ` e nt[0 Y,n�(a <br /> If APPLICANT 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 as It IS available and at the same time It IS provided to me Or <br /> my representative. Al <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: DEC Q D <br /> SAN 110 1016 <br /> F¢�TN OM'eNuny TA`NrV <br /> R",w6 t <br /> ACCEPTED BY: �Q n_ C EMPLOYEE#: 3O/ I DATE: 6 � <br /> Z / <br /> ASSIGNED TO: (�a EMPLOYEE#: )4,2,Z_ DATE: <br /> 1 <br /> Date Service Completed (if already completed): SERVICE CODE: 0(.01 P/E: <br /> Fee Amount: Amount Paid j ��� Payment Date <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />