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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5-bl)�9 P7) M07-cf-O f 3jZ-W 7k5,;2� <br /> OWNER/C OPERATOR <br /> ;J A // I�� /� /`iF �W p H~) CHECK If BILLING ADDRESS I.tjJ <br /> FACILITY NAME `q q'///%�OYS ri, r"', r'-7-/- <br /> SITE <br /> SITEADDRESS �l U s[�1'17 ! / tp A U�' hvL1iJ7N'--4 I q �� T <br /> Street Number Direction ¢ Street Nam <br /> gO e CI Zi Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) S ��6T/ 0 `AA <br /> Street Number Street Name <br /> CITY /LO �d I SLAND ATE ZIP -1 � <br /> PHONE#1 ^I /✓ EMT, APN# PI USE APPLICATION# <br /> ) rGE �? 2/ 2/7ka';�& <br /> PHONE#2 ECT. BOB DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r <br /> I`l CHECK If BILLING ADDRESS 0 <br /> BUSINESS NAME /�{-J„/S FF"✓✓ PHS1NE# <br /> HOME r MAILING ADIA'A%/ t14 es <br /> / -+I r FAX# r7 5 <br /> CITY SfiGG O STATE `/- ZIP I' 2 o tS <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, STAT and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: CG! DATE: <br /> PROPERTY I BUSINESS OWNER Pr OPERATOR/MANAGER ❑ OTHERAUTHORIZED AGENT ❑ <br /> If APPLICANT i5 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 t0 me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEIVED <br /> / DEC 19 1011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTACLu-.. <br /> ACCEPTED BY: EMPLOYEE <br /> ASSIGNED TO: 1 t/\ EMPLOYEE#: DATE: /,;Z- 19 /-/ <br /> Date Service Completed (if al dyoDmpleted): SERVICE CODE: O &/ P/E: Q� <br /> Fee Amount: ' a Amount Paid hr'2 oa Payment Date \Ct I� <br /> Payment Type Invoice# Check# Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />