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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />G EA) E12AL STa 2 E <br />FACILRY ID # <br />SERVI E RI°UUEST # <br />S� D Z ( 3 <br />OWNER/OPERATOR ZonI C //��,, /- <br />1 YIJ I�10 iTt' \ <br />ids `�Ic �L� (/� J <br />y CHECK It BILLING ADDRESS <br />I <br />FACILITY NAME t <br />WT L <br />FAX# <br />SITE ADDRESS 2'zC7. <br />Street Number <br />I Direction <br />MIN/k <br />ame <br />RVG, <br />TP -Ac -q <br />cityZi <br />Code <br />HOME Or MAILING ADDRESS (If Different from Site Address C}uQ[JC(�] <br />S[reet Numb¢r <br />EMPLOYEE #: <br />S N CLEM [7,. I-�-0 <br />or\ Street Name <br />p P- #*' <br />j� [� <br />CITY New �P-r L? -)ACCP} <br />STATE„ ZIP <br />�j <br />C./ _ I„ O <br />LQ U1 <br />PHONE #t EXT' <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />Fee Amount ✓�CJ.'�' d0 <br />r <br />PHONE #2 ExT. <br />45(o. CID <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR ge"W'TE�A 'R- Kte C� <br />CHECK if BILLING ADORE550 <br />BUSINESS NAME <br />coa^iEn-U/Ac- AtzcT } EC /CF:5-7 <br />COMMENTS: <br />PHONE EXT. <br />I -v t Sg <br />HOME or MAILING ADDRESS <br />FAX# <br />Ro�PEpS P <br />CITY fUx O.O " <br />STATE ZIPq'5� <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(reerformed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards ATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ER A II j ITCH <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 assessmenation <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same Owie Or <br />my representative. PF <br />TYPE OF SERVICE REQUESTED: <br />Ca <br />COMMENTS: <br />Ro�PEpS P <br />OESO <br />P <br />NWXA <br />ACCEPTED BY: Ixl.l l <br />EMPLOYEE #: <br />DATE: G', '�?9% <br />ASSIGNED TO: <br />EMPLOYEE#: <br />DATE:S <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />P/E:/ <br />Fee Amount ✓�CJ.'�' d0 <br />r <br />Amount Paid 8 <br />45(o. CID <br />Payment Date <br />- V-� <br />Payment Type <br />Invoice # <br />Check # 1 —1 S <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />Ni <br />