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SAN JOAQLTWCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# y SERVICE REQUEST# <br /> Type of t�usirLes Dr Prdparry --5,le6w 7o <br /> A <br /> OWNERIOPERATOR ) jU ( CHECK if BILLING AonREss <br /> FACILITY NAME ,��„1 n, 011 ( r <br /> SITE ADDeESS <br /> j ,O_ Sfr ¢ amu dx <br /> Numbar 01, Hon <br /> HOME Or MAILING ADDRESS (If DI Brent from Site AddreSa) <br /> _.. �',,. t t "� SHuat Number _ Street Name _ <br /> E STATE zip , <br /> CITY . }} I, ;l r i trf <br /> PHAN <br /> ONE#1 EXT. APN'# Lo USE APPI ICARON# <br /> 7 I <br /> T' 130S DISTRICT LOCATION CURE <br /> PHONF#2 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if Biu UNG ADDRESS L I. <br /> PHONE# EXT. <br /> BUsINess NAME <br /> HOME or MAILING ADDRESS Fax#( ) <br /> CITY STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operatoror 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 appllcation and that the work to be performed.will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Code',s,Standards,STATE and FEDERAL laws.: . <br /> APPLICANT'S SIGNA�UR----IE: DATE:� C <br /> PROPERTY/BUSINESS OWNERO OPERATOR/MANAGER OTHER AUTHORIZED AGENT LJ <br /> If APPLICANT is not the 810 ING PART (hoof Of authorization to Sign is required Ti rte <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above <br /> ddr <br /> site address,;:hereby authorize the release ofany and all results,geotechnical data andlor environmental/site assessment information <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as It IS available and at the same time it Is provided to me OI' <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: �L, j --iii? �L•G., � GC_ <br /> COMMENTS: <br /> QCT 3,! 2014 <br /> ' SAN JOAQUIN COUNly <br /> I�tauttitaMEtaryll, <br /> Nva �a�r ' <br /> .EMPLOYEE#: DAi£; <br /> EMPLOYEE#: ..DATE: <br /> ASSIGNED TO: �— <br /> Date Service Completed (if already completed): SERVICE COOS. (- ,- �� PIE: <br /> tier <br /> Fee Amount: Amount Paid �y r_�.• PaymentD`ate lir 31 <br /> i ,`Cj <br /> =' Invoice# Check# i �". �xT Received By: <br /> Payment Type �t <br /> SR FORM(Golden Ro(l) <br /> EHD 4$-02-025 <br /> 07/17/08 <br />