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SAN JOAQUIN vOUNTY ENVIRONMENTAL HEALTH DEYHRTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST # <br />o I _ <br />si <br />/Tften,a Wa"-1'S <br />`/G 9 <br />r)&3 <br />J��%Gl��(CJ <br />OWNER OPERATOR �� <br />'cy�✓✓ BILLING ADDRESS <br />� Cl/ <br />^*H4CKif <br />FACILITY NAME ,�GC <br />SITE ADDRESS 4-�S <br />C�' 5 Cl 9 O /0 r v14 <br />� <br />/\�- <br />/rel <br />EMPLOYEE#: <br />Street Number <br />Dlreclion <br />beet Name <br />EMPLOYEE#: <br />Ci <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Addressl <br />(/�,,tt Al.�n,f�, <br />�C�� <br />lteet <br />_ <br />Street Number <br />"' Na.._ <br />CITY /_ 1e L <br />(A 007 7 <br />OS DU <br />STATE ^„ ZIP <br />/APPLICATION <br />PHONE#11 <br />t <br />°tf• <br />APN# / <br />s <br />LAND USE # <br />PHONE42 <br />( ) <br />ExT <br />BOS DISTR& <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMEloc/ J ! �i _ �_ - PNONE # �S -33 7 - S' <br />HOME or MAILING ADDRESS I FAX# <br />CITY t"l. J,4` r 11 , STATE ZIP CCj S30 7 <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, STATE and FEDERAL Is <br />APPLICANT'SZQ SIGNATURE: A DATE: ' �— -/ — <br />PROPERTY/ BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ` w/ CO+.d'r '-(OT <br />If APPLICANT is not the BILLING PARTY Proof Of authorization to sign is require O Tif(e <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 prome or <br />my representative. <br />TYPE OF SERVICE REQUESTED: eco op/ Q / / , T <br />D <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />COMMENTS: <br />`/G 9 <br />1 <br />�NdOA C 20 <br />y�c <br />0��MDuN <br />N <br />ACCEPTED BY: <br />EMPLOYEE#: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE: V -a <br />Date Service Completed (if already completed): <br />SERVICECODE: Jr -Z3 <br />PIE: 3 O/ <br />Fee Amount: 0 0 8 <br />Amount P ' <br />OS DU <br />Payment Date <br />W1 <br />Payment Type i C�.f_, <br />Invoice # <br />Ch ck # S1 <br />Race- ed By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />