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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> -- Rk <br /> Type of Business or Property r�FACILITY,ID# SERVICE REQUEST# <br /> ,T <br /> o <br /> OWNER/OPERATOR <br /> CHECK if BILLIIJC-ADDRESS <br /> W btT h�aL r <br /> FACILITY NAME <br /> F J ptf , 01--r <br /> SITE ADDRESS /7�� `.1 I `[� '�1 p C �(� [� '752 V <br /> Z O breet Number Dir A).n �N"'A M I!;froa_r'bfe, � u P To k �:,,r..�„� <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Zqv ���J ,^, t*,;cT ��v`— <br /> Street Number Street Name <br /> CITY STATE <br /> c c��s.s C� Z�52a <br /> PHONE#1 EXT, APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CON'T'RACTOR SERVICE REQUESTOR <br /> REQUESTOR <br /> L h W rc �N C� w CHECK if BILLING ADDRESS <br /> BUSINESS NAME �`- PHON # EXT. <br /> WJC-O VL- 1r c.F o P ���- 79S <br /> HOME or MAILING ADDRESS FAX# <br /> t_� Dei" c ) <br /> CITY 1 JC��� C�& STATE 9-r1 P7 <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 FEDERAL IaWS. c <br /> APPLICANT'S SIGNATURE: 4*� DATE: <br /> PROPERTY/BUSINESS OWNER Ef 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 provide�fti the Or <br /> my representative. /A PAft-".- <br /> ` <br /> TYPE OF SERVICE REQUESTED: Foo G � G �E • <br /> COMMENTS: 2 <br /> tiE Fiyo�ot,IN Z 16 <br /> A(TN OO qRTCo dry <br /> NT <br /> ACCEPTED BY: , ik EMPLOYEE#: DATE: �J� 161 <br /> ASSIGNED TO: tl1 �� V EMPLOYEE#: DATE: V /� <br /> Date Service Completed (if lalready completed): SERVICE CODE: -2 PIE: O i <br /> Fee Amount: Amount Pai P 0� Payment Date <br /> Payment Type Invoice# Check# F l L Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />