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SAN JOAQU..4 COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME J— Iv-P/ V t / ) ` <br /> SITE ADDRESS S 1,�L4 S T, C �--c)ry F71 <br /> 7 S}6. <br /> 3 o6f'NA/,1L'S Street Number Dlrectio i Street Name Ci ZiI3 Code <br /> HOME or MAILING ADDRESS (If Different from :te Address) <br /> / LIZ"I)ZA 6 v 7 ' Street Number Street Name <br /> CITY� I r /A 61 <br /> ,/ zip 5^ <br /> , t S <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> (Zo$ 679 z <br /> PHONE#2 EXT. BOS DISTRICT CATION CODE <br /> LO <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> -}/ V/ I r� 5/ 0 f,7� )u/ S <br /> BUSINESS NAMEfu A CHECK If BILLING ADDRESS <br /> / tr l� PHONE# EXT. <br /> HOME or MAILING ADDRESS t FAX# <br /> 7 I ( ) <br /> CITY r STAT 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 pe:formed will be done in accordance',with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE andFEDERALlaws. <br /> ' _ /� l <br /> APPLICANT S SIGNATURE: G,,, � �1 DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available, and at the Same time It IS provided to me or <br /> my representative. , POMFNT <br /> TYPE OF SERVICE REQUESTED: � `%(� cm1 L'U.W,p,t 0,1 RECEIVED <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL. <br /> W:AL,t1i or-pARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE:(z f { <br /> ASSIGNED TO: l l',t^ EMPLOYEE#: DATE:ll.vl l <br /> Date Service Completed, (if al eadycompleted : ` <br /> SERVICE 'LC,Gj1 P/E: t(ptt� <br /> Fee Amount: I w Amount Paid u V L: Payment Date / f 5 <br /> Payment Type I Invoice# Chft" ` U Received By: L <br /> 3 <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />