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SAN JOAQ N COUNTY ENVIRONMENTAL HEALTHIOPARTMENT <br /> SERVICE REQUEST <br /> Type of si ttes or Property FACILITY ID# SERVICE REQUEST# <br /> /oto 70897 <br /> OWNER OPERATOR CHECK If BILLING ADDRESSLt' <br /> FACILITY NAME Otted T)/ <br /> ` CT-7t-s 11 <br /> SITE ADDRESS !J C <br /> tumber 1 0reetlonSlreel Nem. <br /> ADDRESS (if CI i ode <br /> HOME or MAIUNGDD�I(Jferefrom ntSite Addre s) <br /> �-�- •✓" O Street Number Street Name <br /> CITYSTATE ZIP <br /> 1 e�ca� C.v* ':�I� IS I <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> PHONE#2 Ext. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# fit• <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknovledge 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 C&9 'Standards,STATE and FEDERAL laws. I <br /> APPLICANT'S SIGNAL �-- DATE: Ib 3 r <br /> PROPERTY/BUSINESS OWNER0 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 assessment Information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time It IS provided t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: l <br /> COMMENTS: a <br /> EIVE <br /> OCT 3.1 2014 <br /> SAN JOAQUIN COUNTY <br /> €NYiROMENTAL <br /> 1,1EALTH eLPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: PIE:�Uz <br /> Fee Amount: Amount Paid ,/: Payment Date <br /> Payment Type '"7, Invoice# Check# / Received B 1 <br /> G y: <br /> EHO 48-02-025 <br /> 07/17108 <br /> 07/17/08 �'1 /�LJ� r I J (p SR FORM(Golden Rod) <br />