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SAN •JOAOUIN COUNTY EWRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID <br /> SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS s <br /> J?( i�7/O <br /> lreetNumber Direction / >3treet Name � (�/� FZ i.o Codes <br /> HOME Of MAILING ADDRES (11 Different from Site Address) <br /> f street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> -�• yb <br /> PHONE#2 EXT. <br /> `) _ BOS DISTRICT LOCATION O E <br /> 00 <br /> CONT—RA.CTOR SERI"aCE PEQUES A®R <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME / PHONE# EXT. <br /> ';,4 23 V--0cl; <br /> HOME or MAILING ADDRESS FAX <br /> #!go )��3`�/ O <br /> E Xi/ <br /> CITY O (STATE ZIP <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 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �r,/ I V t��l�w C DATE: 0 ('� � Z — is <br /> PROPERTY/BUSINESS O`NNER❑ OPERATOR i MANAGER ❑ OTHER AUTHOR17ED AGENT ❑ <br /> IfAPPLICANT 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 asses!��r <br /> enion <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at the Same time It ISOr <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: u� <br /> COMMENTS: SAN� <br /> 15 <br /> OAQUuy CNTHp3HALAE <br /> ACCEPTED BY: IV(A A r p II/�J EMPLOYEE#: DATE: <br /> ASSIGNED TO: B 1�lf'— EMPLOYEE',: DATE: l <br /> Date Service Compl ed (if already mpleted): SERVICE CODE: 46 1 P/E: <br /> Fee Amount: c36 Amount Pai 3,0. 6D Payment Date I �S— <br /> Payment Type Invoice# Check f Received By: <br /> EHD 48.02-015 Sr F0r=1.i(Go!deni Rod) <br /> 07/17/08 <br />