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3- <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUES # <br /> OWNER 1 OPERATOR CHECK if BILLING ADDRESS <br /> C20--b< <br /> FACILITY NAME ` <br /> SITE ADDRESS �-1 G � �� �� <br /> Street Number I Direction Street Name Ci Zi Code <br /> HOME Or MAILING qADDRESS (lf Different from Site <br /> ^^Address) <br /> P-S �/! �[ b o l -'- Street Number Street Name <br /> CITY STATE CA ZIP <br /> 1'L <br /> r_ D PHONE#1 E"T APN# LAND USE APPLICATION# <br /> V l (531)1 b,';lQ--15 3-7e)D-6 �J1 <br /> PHONE#2 EXT. BOS DISTRI LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR ! CHECK if BILLING ADDRESS <br /> BU5INEss NAME1! PHONE# En. <br /> ro s _ Ca-F�e s r Q <br /> HOME or MAILING ADDRESS FAx# <br /> CITY STATE C"9- ZIP <br /> �3'5a-6 s+mr'k'�My�" ��Ij <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, " <br /> acknowledge that all site andlor 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 /> 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, Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �d DATE: J <br /> PROPERTY I BUSINESS OWNER❑ OPERATA I MANAGER © OTHER AUTHORIZED AGENT L7(1 DpV (l{Q�l y ly)J1 <br /> If APPLICANT i5 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 /> to 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. <br />' TYPE OF SERVICE REQUESTED: <br /> PAYMENT <br /> COMMENTS: RECEIVED <br /> SET' z 5 2011 <br /> SAN JOAQUIN COUNT) <br /> ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: DAT&�VT 5A <br /> UE <br /> ry IT <br /> ASSIGNED TO: EMPLOYEE#: DATE: q 5 <br /> Date Service Completed (if already Completed): SERVICE CODE: CIO S PIE: 1 1 <br /> Fee Amount: c5QC5" Amount Paid -- Payment Date C1 , S 17 <br /> Payment Type U Invoice# tl ec a �� ` Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />