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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> l_1C�Scl,�� 'Secv,cc C�&I)Gi) �97 7-3 62-o0&0 -7 11? <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME �� t <br /> SITE ADD70"D 1 1� C.�til 1 1���� 1CA <br /> 1 v�—I� I L 1 1��C% <br /> Street Number Direction Street Name Cit Zi Code <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 /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> a�` DU CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> ll..�! r1 PHON # EXT. <br /> I 1 �yr Na c � .�C• /K1CLfV 9 <br /> 1 C (� <br /> HOME or AILING ADDRESS FAX# <br /> a I (b M( y\0A U-X7aN a ,C-32 i 1�� <br /> CITY ? Q� STATE / ZIP Gj <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorlizle�d agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this app 'catiQn and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, MATE <br /> FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> I <br /> PROPERTY/BUSINESS OWNER❑ O ATOR/M NA R OTHER AUTHORIZED AGENT CJ�G" <br /> 1 APPLICANT is not the BILLING PAR Y o0 o t ation to sign is re uire Title <br /> 1 P l l g q <br /> AUTHORIZATION TO RELEASE INFOR [AN: V41 applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: 5 e4�a pAyMEN <br /> COMMENTS: BEC <br /> AUG _ 42010 <br /> SAN JOAGIUIN COUNTY <br /> ENTVi H DE ARTME <br /> ACCEPTED BY: o /s EMPLOYEE#: - DATE: €i 4) <br /> ASSIGNED TO: •vL� EMPLOYEE#: 3 Sp DATE: I G <br /> Date Service Completed (if already completed): SERVICE CODE: /�� P/E: Z O <br /> Fee Amount: Amount Paid -0 366 Lo Payment/Date Lk I O <br /> Payment Type Invoice# Check# 5a� Received By: ff� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />