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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G�CTS S�vl ii,�'1 l.o� C �e 1���JIS�GC� S�UO <br /> OWNER/OPERATOR ; <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME IW <br /> SITE ADDRESS S L'& / rC I-I{- 1-1 Yi e I f j( �rGti <br /> Street Number I Direction C' Street Name C Zip Code <br /> HOME or MAILINGADDRESSS (If Different from Site Address) <br /> "_5 0 1 1 �"- �� Street Number Street Name <br /> CITYCt STATE ZIP <br /> S ✓1 Y�c n G1 S t o <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# I <br /> k5) 522 - 2 �3-7 <br /> PHONE#2 EXT SVS DiSTRiCT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1 `� �� <br /> 1 ( CHECK If BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> V I S-e vt�� S <br /> HOME or MAILING ADDRESS FAX# <br /> CITY S o' 1/.AC, STATE ZIP 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 /> 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 andEDERAL laws. / t <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY/BUSINESS OWNER® 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. RAY IYT <br /> TYPE OF SERVICE REQUESTED: �v \ (� �1RECF muck <br /> COMMENTS: JUN i -�j ."' <br /> ?6 � <br /> SAN UME COUNTY <br /> HEALTH DEpAHTAL <br /> MEN-" <br /> ACCEPTED BY: ` EMPLOYEE#: DATE: (Ph g i S <br /> ASSIGNED TO: J, (�� NJ EMPLOYEE#: DATE: /11// <br /> Date Service Completed (if already completed): / SERVICE CODE: PIE:��02, <br /> Fee Amount: '%_C;'c--;, Amount Paid !3 0 Payrnent Date <br /> Payment Type ✓ Invoice# Check# S/ Received By: <br /> EHD 48-02-025 SR.FORM(Golden Roc) <br /> 07/17/08 <br />