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SAN JOAQUIRCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property �..__ D00 11" ` RCO-73-2 Tq— <br /> OWNER I OPE RAT R .J CHECK If BILLING ADDRES' <br /> -- 61-4 1611 5V �. _�z 41 JS IL <br /> FACILITY NAME ' S (I"\ S <br /> SITE ADDRESS �1 rl ✓n tvV—r L� r�< 1 <br /> 1 (� CI Zi Code <br /> re <br /> L{, 5[ e[Number Direction Stre¢[Name <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP <br /> CITY <br /> PHONE#1 ExT. APN# LAND USE APPLICATION III <br /> ( ) <br /> EXT. BOS DISTRICT LOCATION CODE <br /> PHONE#2 <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> Em <br /> BUSINESS NAMEI tiPHONE# <br /> 5 et � ti�+IIL�l t o� �o - �l - l Cv <br /> HOME or MAILING ADDRE/g5 FAX# <br /> CITY STATE &) ZIP O I /1 J <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, S TE and FEDERAL laws.(� <br /> APPLICANT'S SIGNATUR .s-L��I ��5✓�� - r� �-,.��a—� DATE: I ' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER I 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, 1, 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 to me or <br /> my representative. '^ P <br /> TYPE OF SERVICE REQUESTED: fhod �jV�� -I T Z;V dvk ECC J T <br /> COMMENTS: SEP g <br /> J O 2O1 <br /> SAIV H A NVgOME COU Ty <br /> LTH DOPARTM <br /> fr <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: f, EMPLOYEE#: DATE: <br /> Date Service Competed.(it already completed): SERVICE CODE: �L(�lf/ I PIE: ICnoZ <br /> Fee Amount: 41ej) Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />