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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C Leuning a 0D 2 z z'� --T S�z M R co 3� <br /> OWNER/OPERATOR 41 * mi i cIbl, 1�O(CI I, (� n 6,-H-eo, <br /> XL <br /> Sn� CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS3 -,/�/seFN,/�51/�J <br /> umler Direction C d� <br /> HOME or MAILIRESS (If srent from Site Address) <br /> P1ox 291 Street Number Street Name <br /> CITY STATE ZIP q <br /> PHJ](vE#1 �'}q xT APN# LAND USE APPLICATION# <br /> PHONE i#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <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 a d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: `� ( � A <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAG ❑ OTHER AUTHORIZED AGENT ❑ <br /> if APPLICANT IS Ot the BILLING PARTY,Pr of 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 sametPAYMEWto me or <br /> my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: CSS C�fi1 SU �-tn--h(-M <br /> COMMENTS: <br /> JUN 12 ZU19 <br /> 'P P, 6 'St> SAN JOAQUIN COUNTY <br /> C QRS i� '� ENVIRONMENTAL <br /> G O `T HEALTH DEPARTMENT <br /> ACCEPTED BY: -�w ,n h EMPLOYEE#: DATE: <br /> ASSIGNED TO: 11 0 n�) EMPLOYEE#: DATE: 6/I�- )CI 1 <br /> Date Service Completed (if already completed): SERVICE CODE: (�� 1 P/E: (-I IC)Z <br /> Fee Amount: 1�2,� Amount Paid lk ` Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />