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SAN JOAQUIIV COUNTY ENVIRONMENTAL HEALTH <br /> EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -7 V--5r <br /> kwoo s 9 b <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 4+ %Ao <br /> SITE ADDRESS �''n10 C <br /> Street Number I ion c7` t Street Name Cit v'v Zip Code <br /> HOME Or MAILING ADDRESS,y../}If Different from Site Address) <br /> •O' ' Street Number <br /> Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# 17 3 —O LAND USE APPLICATION <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> 1 1 11 �211 <br /> - <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR U CHECK If AILLING ADDRESS <br /> BUSINESS NAME �+ EXT. <br /> 9 <br /> HOME or MAILING ADDRESS 1 FAX#TSL 1 1 7D 'I <br /> CITY STATE ZIP /} M <br /> '�I ISdd <br /> BILLING ACKNOWLEDGEMENT: 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 <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,StandardsA-ILLINGPARry <br /> laws. <br /> APPLICANT'S SIGNATURE: DATE: ,1 IS 0 <br /> PROPERTY/BUSINESS OWNER❑ OPE ❑ OTHER AUTHORIZED AGENT tZ <br /> If APPLICANT is not/heOf authorization t0 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 t0 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: (�[,S T ,��'��! T pp,YM <br /> COMMENTS: R <br /> JAN 9 2008 <br /> SATN pN'JREMPAETENIOfMI'tT <br /> ACCEPTED BY: �(rt (/r'I /Ll iI EMPLOYEE#: 03 DATE: d <br /> ASSIGNED TO: NI4--1 OL-t. EMPLOYEE M Q DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: g e P It�.3 0� <br /> Fee Amount: 5Q T 0-7 Amount Paid d q t Payment Date <br /> Payment Type ✓ Invoice# Check# 1 (o I LA Received &T <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />