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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 4r1 - o SiZcc X200/ <br /> OWNER/OPERo A OR z fir <br /> CHECK If BILLING ADDRESS le <br /> FACILITY NAME ' <br /> Ci ui <br /> SITE ADDRESS <br /> '3 Za`�' ICD C-14�T� r— S i t�ltiTtsc'�a— q K-3.37 <br /> Street Ndmber Direction treat Name cityCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) S e 1 ti O C� __` <br /> Street Number I� rtr7eaft Nama <br /> CITY STATE zip <br /> i" `tawc t�� Lsp 9 S'3 3l <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> I 1 11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 4 C'U CHECK 11 BILLING ADORES <br /> AP <br /> BUSINESSN PHONE# EMT. <br /> a Y l <br /> HO orMAILINGADDRESS FAX# <br /> v <br /> CITY A. STATE c1104 ZIP 0 <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 <br /> or 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 laws. <br /> APPLICANT'S SIGNATURE: � /� DATE: �Z3rI <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT 1­1 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the Same time It is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 'p,t L.Z_ K£1 LLO Vk PA <br /> COMMENTS: CENED <br /> FEB 2 3 2011 <br /> SAN JOAQUIN COUNTY <br /> HE�Rp ARTMENT <br /> ACCEPTED BY' - EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE III: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O <br /> Fee Amount: O 1) Amount Paid PaymentDate <br /> Payment Type Invoice# Check#Iil R eived y: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />