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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1;�A OW 2-LAWW Dom�43 <br /> OWNER/OPERATOR <br /> ` r `T ';�'A/ CHECK if BILLING ADDRESS <br /> FACILITY NAME \� 1 1 f �/` V / <br /> SITE ADDRESS 6 / �✓�C ��o Gttm <br /> G D (0. Street Number Direction �Str?eeVt Name Cit Zi OClode <br /> HOME Or MAILING ADDRESS (If Different from Site Address) 1 d� ,e ^ ) <br /> o U <br /> Street Number Str ► A v <br /> eet Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN r LAND USE APPLICATION# <br /> (A'0 ) oS'-PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> PHONE# ExT. <br /> BUSINESS NAME YV1 c�.�cnf� �v�nit N Cil n e, Nos -225 s <br /> HOME Or MAILING ADDRESS FAX# <br /> Is S. t3 goo VS1 J ( ) <br /> CITY + M w vtc n STATE zip C, <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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �A ,'y)y DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑�re�� <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 provided t0 me or <br /> my representative. 1 <br /> TYPE OF SERVICE REQUESTED: T Ilt/ ���Vl/1 ,.bV� <br /> COMMENTS: 1 I � V L tn� �0&V0 <br /> 4 t.'N 0 7 20 8 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: LwAr%1 EMPLOYEE#: DATE: r ' <br /> ASSIGNED TO: L . 1' ✓ Y t,) - - EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: d(D V PIE: 1�V I Z <br /> Fee Amount: Z Amount Paid l S 2-- Payment Date (,l <br /> Payment Type ! Invoice# C,Jtec # g Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />