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SAN JOAQtjt1q COUNTY ENVIRONMENTAL HEALTH UtPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> \: CHECK If BILLING ADDRESS <br /> FACILITY NAME G�G p r1 1L�)>'t/ .r,v�zu G�y.i yr2c.✓ <br /> SITE ADDRESS .�5 Z L s-;eS- <br /> Street Number Direction - Street Name Ci Zio Code <br /> HOME Or MAILING ADDRESS (If DifferenA from Site Address) <br /> s <br /> Street Number Street Name <br /> CITY V STATE LA <br /> ZIP 9�-2/V <br /> 12- _ 'C- beTo <br /> PHONE#1 -� EXT• APN# LAND USE APPLICATION# <br /> V-) ) Goa, C7 ?l <br /> PHONE#2 / EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE PEA QUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME G� PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <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 /> 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. l <br /> APPLICANT'S SIGNATURE: )',,Two LILo S DATE: �1 / a0Lt- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> IfAPPLICANT 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 assessmon <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is pryer »4 N`� <br /> my representative. �1'"'f�t E� <br /> TYPE OF SERVICE REQUESTED: FES x <br /> COMMENTS: SAN JOAQUIN C <br /> OIJ <br /> HEA rH DEpgATAM NTM <br /> NT <br /> ACCEPTED BY: Vr1�7/v� EMPLOYEE#: DATE: f <br /> ASSIGNED TO: v EMPLOYEE#: DATE: <br /> / ,1 <br /> Date Service Completed (if a ady completed): SERVICE CODE: 6 P/E: �U Z <br /> Fee Amount: /-2, - Amount Pal �3d, ©D Payment Date <br /> Payment Type Invoice# Check# Received By , <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />