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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />Y' Po N � e- c-4 <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE #: <br />SITE ADDRESS <br />a1155 G U�St.0{ R�ber <br />ree Numction <br />Dire <br />; o � � � <br />S U,r./Street Name <br />H�� j���o- <br />CI <br />�%�.3� 7 <br />Zi Code <br />HOME Or MAII}W5 ADDRES�(if Different from Site Address) <br />1 D box U i <br />Street Number <br />SERVICE CODE: <br />Street Name <br />CITY � T- <br />r1("� <br />Fee Amount: ` <br />STATE ZIP _ <br />�J3 <br />PHONE #1 EXT. <br />()-,69 7 1— L4,5--.5— <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />Check # ' (7 / <br />BOS DI$rZ <br />� <br />LOCATION CODE <br />REQUESTOR Ld,1�L <br />J,1 <br />1 <br />BUSINESS NAME c� <br />HOME or MAILING ADDRESS <br />CONTRACTOR / SERVICE <br />M ��``���n 6usat <br />aAru A - <br />Dy 4oto <br />�j lCI3y'y CHECK if BILLING ADDRESS E] <br />M&A # EXT. <br />�' STM AGE ZIP 2 <br />CITY ��-%ec 5' xIfA <br />u -- �J S <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 that4he work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STATE n FEDER I WS. <br />APPLICANT'S SIGNATURE: DATE: /oZ z/ -moo i <br />PROPERTY / BUSINESS OWNER OPERATOR/ 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, 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 Or <br />my representative. I <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />/` ' s�O l f-xLe� <br />irgt <br />ACCEPTED BY: <br />Il <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P / E: <br />Fee Amount: ` <br />2 <br />Amount Paid <br />Payment Date <br />Payment Type i <br />Invoice # <br />Check # ' (7 / <br />Received By: <br />EHD 48-02-025 <br />07/17/08 <br />PAYWa L'N I <br />R <br />ECbaniVE:0 <br />DEC 2 1 2067 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />Ur_Ai Tu nF'DAPTkAFtUT <br />SR FORM (Golden Rod) <br />