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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property (�«. S-6,0-, f1 FACILITY ID# SERVICE REQUEST# <br /> St ow Std l' <br /> 4LG48 „ a [g�.CZ74?jta� <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> { V U <br /> FACILITY NAME <br /> .4 QQ <br /> SITE ADDRESS Ma n La A P. 1..001 <br /> L I Street Number Direction I` �T Street Name CIN Zi Cotle <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PH0NE#1 EXT' APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR SERVICE REQUESTOR <br /> REQUESTOR ' l L 1 <br /> \1MVTIh eJr�e1� CHECK If BILLING ADDRESS <br /> BUSINESS NAME11�� PHONE# EXT' <br /> M m o 4� S�et1 r& &r•ck' -',cc� C-. 5 OC ( 51P 8&'i-1 74 <br /> HOME or MAILING ADDRESS FAX# <br /> v' ( ) <br /> CITY STATE CA zip61.5& <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or paSTATE <br /> NVIRONMENTAL HEALTH DEPARTMENT hourly Charges associated with this project or <br /> activity will be billed to me or my bfied on this form. <br /> I also certify that I have prepare nd that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Stan arDERAL laws. <br /> APPLICANT'S SIGNATURE. DATE: <br /> 3.Lq I(ice <br /> PROPERTY I BUSINESS OWNER El OPERATOR/MANAGER E3 . <br /> OTHER AUTHORIZED AGENT �c.rGIAIT eC+ <br /> If APPLICANT Is not the BILLING PARTY,Proof of authorization to sign Is required Ti rle <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 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: r <br /> COMMENTS: <br /> ,(lrChlfeCf �� �rYl tilp elec�1C ale . PAYMENT <br /> RECEIVED <br /> i,. 0 9 2015 <br /> N JOAQUIN COUNTY <br /> E �IIftOtJl TAL <br /> ACCEPTED BY: EMPLOYEE#: UATEI 3- fMDEPFITMENT <br /> ASSIGNED TO. EMPLOYEE#: DATE: �- _/ <br /> Date Service Completed (if already completed): SERVICE CODE: �� PIE' <br /> Fee Amount: A40 oil Amount Paid ` C Payment Date <br /> Payment Type - , Invoice# Check# _ - Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />