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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> t��tic�,s c ova m�v�� sol Az 6p,661 a Lt W <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS© <br /> FACILITY NAME <br /> SITE ADDRESSCOW G (///P r ( ; /l// �( <br /> scree[ mbar Direction I� Street Name _ _ L'o � Zn C A <br /> Ijor�F.Or MAILING ADDRFS$ Different fr mSit dress) 1 Q ,IJ- <br /> Q�YY� Street Numbery+71 'Streef Name <br /> CITY clrr�J ^ ^ ZIP C <br /> PHOP:r#t '`"((J[,• '7 ExT APN# LLAfAD`USE i. -.0 C+TION# <br /> tu) 3I - (5 IS <br /> PHONE#2 Ezr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR — <br /> REQUESTOR ,,n 'J1_ <br /> � // ,/yyV` v.(7)/I/tt .O�n� i'] CHECK It BILLIn'G ADDRESS® <br /> BUSINESS NAME r�L /// VVV II, Tw Y (/I/J l/ PH E# EXT. <br /> p�P ymm O au-- RS la�':3- 112 <br /> Ill C�Hp or MAILING ADDRESS C �v l� � FAx# <br /> I CIU` C7 STATE / ,Ll ) ZIP rte)%f,�oJ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorizedl 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 /> also certify that I have prepared this ap I'c do and that th work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standar s,ST r n my_ <br /> APPGCANT'S SIGNATURE: DATE: �I / r-7,0� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT J-(^� <br /> If APPLICANT is not the BILLING PARTY,proof Of authorization f0 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 /> 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: Z •��i( T / I�-.Q��C - p�ZQ{J�,'D <br /> COMM TS: -t 1 r� _} Gei✓fY1'�1"I t M V I'A,-(-I • A`�!� L� <br /> L'GVI n �cNT <br /> ""N�P'p"�^/� 12a IR r . Jar r o n b ��• cis`to 444 1?,. <br /> VSO <br /> n 1_ vur� �o@ Q latkl' C` to Sq� SOA 20/6 <br /> HF N�/q r'/Col/ <br /> ACCEPTED BY: EMPLOYEE#: DATE: �f- Fpq Tq�Nn, <br /> �/ /�. MEM <br /> ASSIGNED TO: W EMPLOYEE#: DATE: 3�J I(e <br /> Date Service Completed (if already completed): VICECODE: 1523 PIE: IQ pcY/ <br /> Fee Amount: 4. Amount Paid (.� < Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />