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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> sGz.66 79 /S <br /> OWNER/OPERATOR <br /> /'/I n/t,ry <br /> I/( (f- �I � CHECK If BILLING AODRESSO <br /> FACILITY NAME i 6;A, 47 <br /> ./�� I` /(- <br /> SITE ADDRESS <br /> C- StreetNumber I Direction emZi CadtlV <br /> HOME or MAILING ADDRESS (If 2. Diffrent from Site Address) <br /> 0 / �� Street Number Street Name �/ <br /> CITY O"' 7�` I'1 �L _,v SJAT Zip <br /> f C <br /> d 19 <br /> PHONE#1 l f ` ExT. APN# GLAND USE APPLICATION# <br /> �Cv,) Yui- I 6 q ll b 15' <br /> PHONE#2 ExT. BOB DISTRICT LOCAON CODE <br /> ( ) OUB � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR KC <br /> "A fele- <br /> P� 6/ / n <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME M 1, <br /> P( <br /> NEca# EXT, <br /> HOME Or MAILING ADDRESS117> /v /-C/ /F7C FAX# <br /> CITY Leto" . C fes/ STATE ZIP ( 1 V Z <br /> BILLING ACKNOWLEDGEME T: 1, 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, ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: -;%7/ DATE:: <br /> PROPERTY I BUSINESS OWNER❑ PERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT R C e1L-74ACrG--z <br /> If APPLICANT is not the BILLING PARTY Proof Of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at th above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assess mation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as SOOn a5 If IS available and at(tie Same tlmP�{t�{r rl i a Or <br /> my representative. rrr- ����yV <br /> TYPE OF SERVICE REQUESTED: Q� I0% <br /> COMMENTS: <br /> wk,��aeN�N�w <br /> s� a p�tM� S <br /> ACCEPTED BY: ( vr EMPLOYEE#: DATE: <br /> ASSIGNED TO: 1 EMPLOYEE#: DATE: UU$ aa <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: 4 Amount Paid $u 50V Payment Date 2Z Veg <br /> Payment Type Invoice# Check# lqq Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />