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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> — Pt-OrAAL� F-111\ 0 ol 6c)S3, 546 o <br /> OWAR/OPERATOR �^'►li(.J <br /> CHECK If BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS <br /> reet Number ecIion <br /> HE or MAII INC ADDRESS llf Different from Site_Address <br /> 10 GN Lli> reef Number Street Name <br /> CITY V STATE ZIP <br /> PHONE#1 EXT, AP N# LAND USE APPLICATION# <br /> 10(x- 010 - 01 <br /> PHONE#Z EX7. B05 DISTRICT LOCATION CODE <br /> V <br /> ( ) 1 <br /> CONTRACTOR SERVICE REQUEST®R <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 an DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: I <br /> PROPERTY/BUSINESS OWNER. OPERATOR/MANAGER El AUTHORIZED AGENT ❑ <br /> If APPLICANT�inot the BILLING PARTY proof of authorizat n to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property locatedat the above <br /> site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site/a�ss�essme.nt information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same tIrrvlded to me or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: -� � t- V�nt�_D <br /> COMMENTS: SAN 1 V IBJ <br /> n 1�,,, � 11 SDA <br /> N4J ©(oyl9--f yF iTH�ooME CDUnrry <br /> EPgRTAL <br /> ACCEPTED BY: �^ a 1� EMPLOYEE#: DATE: <br /> ASSIGNED TO: , EMPLOYEE#: DATE: <br /> Date Service Completed (if already com eted): SERVICE CODE: / PIE: [ 2 <br /> Fee Amount: �12�U Amount Pai WOO Payment Date �J u <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48.02-025 SR FORMI(Golden Rod) <br /> 07/17/08 <br />