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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property t FACILITY ID # r-SERVICE REQUEST # <br /> OWNER / OPERATOR <br /> r ` o vN ec + s / n CHECK If BILLING ADDRESS <br /> MI <br /> FACILITY NAME A c o A� <br /> SITEAD/D�RESS \Wr co /0v1 ��{ lOn 9 S3G6 <br /> 1 3 -r 0 Street Number Dtctlon Street Name CI ZI codo <br /> HOME or MAILING ADDRESS (If Different from Site Address) ^ <br /> Street Numbor Street Name % ME� <br /> CITY STATE zip �� <br /> PHONE # 1 ExT• APN # LAND USE APPLICATION # D <br /> c ) C <br /> PHONE #2 Exre SOS DISTRICT LOCATION C <br /> f ) NEAL V/ JAa MEcOUNry <br /> CONTRACTOR / SERVICE REQUESTOR PARrMFNr <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAM <br /> (� PHONE # Exr. <br /> HOME or MAILING ADDRESS OF FAX # <br /> 36ig kllA2C4 ( ) <br /> CITY OC 1'�%' STATE CA zip 9 y5a 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 that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL �trSf. <br /> APPLICANT' S SIGNATURE 1 ` DATE : <br /> i <br /> PROPERTY / BUSINESS OWNER ® OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> /f 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: ��, I / '� / ' <br /> COMMENTS: arm <br /> o ,,.e p 1Zee � �1 FFs �h � � Tt /C Ska1,5 ki- �0 ?/.GeW ,� 1 A' <br /> J .� l <br /> e 4cw der d ro� 7W e, w . A aoow ,�' �/ e.ve d to <br /> llC.lvf ) 4v cavHy /c wt�A Yiv A✓tr4ll Ptl«lTisiI Fj 111" ewi Aft e <br /> ACCEPTED BY: n , EMPLOYEE #:IL DATE: l� � � .ZJ <br /> ASSIGNED TO : E EMPLOYEE #: DATE/ /)f/ <br /> Date Service Completed (If already completed): -�-- SERVICECODE : C)S 2 P / E: - -� �� <br /> Fee Amount: �, Amount Paid, T� Payment Date � l <br /> Payment Type S Invoice # Check # 132 �[f 7 g Received By: <br /> EHD 4&02-025 SR FORM (Golden Rod) <br /> 07/17/08 <br />