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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIi DEPARTMENT <br />10 SERVICE REQUEST 0 <br />Type of Business or Property <br />GK' S A <br />FACILITY ID # <br />5�q <br />PHONE # EXT. <br />SERVICE REQUEST # <br />M V -76' 3 <br />OWNER /OPERATOR S) ��\\ '�t <br />„ Ik K� n1 f A <br />S/SS+ <br />CHECK If BILLING ADDRESS E] <br />FACILITY NAME nt I n . I ;—:� I �,v C '� 1 I D� <br />e <br />SITE ADDRESS goo <br />Street Number <br />Direction <br />� y �� <br />�treet Name <br />Ci <br />�Q ?, `F2 � _ <br />Zip Code <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />SAN JOAQUIN COUNTY <br />Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />(ZOw) 3 f -9�ESaj <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />(2 ) �3��—Z)12 <br />BOS DISTRICTLOCATION <br />CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR F— �, F V CD K, ^T-2 W A ` j CHECK If BILLING ADDRESS E] <br />BUSINESS NAME � � (.� <br />PHONE # EXT. <br />HOME or MAILING ADDRESS <br />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 />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: DATE: <br />PROPERTY/ BUSINESS OWNER 91, OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT is not the BILGING 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 <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. <br />TYPE OF SERVICE REQUESTED: <br />PA <br />COMMENTS: <br />RECEIVED <br />NOV 7 2005 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />EMPLOYEE #: :73 A, <br />DATE: (,, S <br />ASSIGNED TO: t.uG <br />EMPLOYEE #: &q9 3 <br />DATE: H -0:? -05: <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />t C} g <br />PIE: Z36 <br />Fee Amount: Z� <br />Amount Paid <br />O u <br />Payment Date <br />Payment Type <br />Invoice # <br />Check # `S CN, 1A <br />Received By: N F <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />