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I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT i <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L1 vor Sforc- <br /> OWNER!OPERATOR (t,I„ <br /> I I(J+ ONE'GK If BILLING ADDRESS C� <br /> FACILITY NAME S Marke-I� <br /> SITE ADDRESS I � • fl�/L IUY)te-cq/CJq- QI�33 7 <br /> Street Number DirectionStr,Y,• e�,•_„et Name city Zip Cade <br /> HOME or MATING ADDRESS (If Different from Site Addrets) >+Li/C1 S'[�p1- h a()9:!-0 S-+ <br /> _ t _ Street Number Street Name" _•_„ <br /> CITY STATE ZIP <br /> "f 6 nte.-o, CA P 7 <br /> PHONE#1 EXr APN# LAND USE APPLICATION# <br /> r PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REQUEST®R <br /> REQUESTOR t <br /> CHECK If BILLING ADbRESM <br /> BUSINESS NAME mark, <br /> _e- PHO n) S-S�_Q'35—�{ <br /> EXT. <br /> M <br /> HOME Or MAILING ADDRESS J /J J"J � FAXC3#1 <br /> 1069 Bch'qff hqu eh S+ t <br /> l CITY STATE ZIP <br /> II"�y1+ecr� eA 9513-7 <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 and FEDERAL laws. <br /> APPLIC,`;AT'S SIGNAT LIRE: G}l i DATE: <br /> I <br /> PROPERTY/BUSINESS OWNER OPERATOR i MANAGER ❑ OTHER AUTHORtzED AGENT ❑ <br /> IfAPPLICANT is not the BILLING PARTE,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 /> I site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information <br /> to the SAN JOAOUIN 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 /> COMMENTS: <br /> SAN JO 2016 <br /> "'QU1 <br /> I HEA t", O of f Trp <br /> M <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> I <br /> ASSIGNED TO: �[/(1�///a V1 InQ LI�ha!eG EMPLOYEE#: DATE: 2 ((0, <br /> Date Service Completed (if already completed): h� SERVICE CODE: Pi E: �( <br /> Fee Amount: ` rt}NGD Amount Nkib ISO �)57 Payment Date ff,9,7M, <br /> E Payment Type ✓ Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> `l <br />