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' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> '4P9r�� IS go <br /> .� �o <br /> OWER/OPERATO <br /> )I M �0�(AtQa� <br /> Qr ,�l CJD CHECK if BILLING ADDRESS <br /> ff <br /> LIT <br /> FACIY NAME ►iW Mflit' 1• fVr �j VK/ <br /> SITE ADDRESS ` ' D�^• <br /> 17 Street Number Dfirevction (! v f reet Nam it Zi Codc <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (moi) ebb 7 <br /> PHONE,'t2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 4--✓�(//�'� �_N� CHECK if BILLING ADDRESS <br /> BUSINESS NAMEPHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <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 d FEDERAL 12WS <br /> APPLICANT'S SIGNATURE: DATE: �� Z2 Zv►y'(/ <br /> PROPERTY/BUSINESS OWNER LY OPER TOR/MANA R El OTHER AUTHORIZED AGENT El <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Tirie <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 to me Or <br /> my representative. PAYM T <br /> TYPE OF SERVICE REQUESTED: t Q� eGI tC I �, D <br /> COMMENTS: <br /> Ghe <br /> Ak, z 2 2118 <br /> f <br /> SAN JOAQUIN CC UNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: � � DATE: /,D '�d I <br /> ASSIGNED TO: b Q h EMPLOYEE#: 4 DATE: /2/;L1e <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E:o0 <br /> Fee Amount: 6;b Amount Paid Z_ Payment Date 1,0 7 <br /> Payment Type ( V Morvoice# Chic S (p �.� a Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br /> fwo IQO"r <br />