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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 1pi- 44.1-0P S�-O�lsa�v <br /> OWNER(OPERATOR !� 1 <br /> CHECK if BILLING ADDRESS® <br /> FACILITY NAME �T <br /> SITE ADDRESS -72z 4(a T^'P&1K � qn—'—< p" <br /> Street Number Direction Tv 'J 7rstree[Nl acme _ eM Zi Code F' <br /> HOME Or r MAILING AD�RESS (If Different from Site Address) <br /> C,f�4T 3 Street Numbemer Strelet�Nhame (1�7 <br /> CITY r !` STATE ny{,y ZIP <br /> PHONE#2 Exr.NE#� EXT, APN# LAND USE APPLICATION# <br /> PH <br /> ( b 2 - 07v — !)L3 9� 6 <br /> oD b nt� <br /> PHOBOS DISTRICT L ATION CODE <br /> CONTRACTOR / SFRVICE REQUESTOR <br /> REQUESTOR f, <br /> -, � ml ctCHECK If BILLING ADDRESS[ <br /> /V W /�(M�MC[ '�, t£�� <br /> BUSINESS NAME � ( PHONE# EXT.�D <br /> HOME Or MAILING ADORES <br /> FAX <br /> CITY �.1 _G.' STATE �p ZIP <br /> BILLING ACKNOWLEDGErAENT: 1, 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: Cao Laj' c, � l�JaL DATE: <br /> �` r� A <br /> ,^ <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT IS--CBV 9p <br /> If APPLICANT i5 not the BILLING PARTY,Proof Of authorization to sign is required )Till, <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 /> 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. <br /> TYPE OF SERVICE REQUESTED: O &,IfaJ21Uft .(t RE <br /> COMMENTS: <br /> JU( 1 <br /> SAN JO 5 Z�I <br /> �t w � HEAL HR MA�OUAlry <br /> AL <br /> T <br /> ACCEPTED BY: N 10/A/1 n Iii O Y� EMPLOYEE#: DATE: ' <br /> ASSIGNED TO: -I r``��l✓�l, `O 1- 1 EMPLOYEE M DATE: (�- I/n <br /> Date Service Completed (if already completed): SERVICE CODE: 'G a- P, <br /> Fee Amount: Amount Pa(off d C� Payment Date <br /> Payment Type Invoice# Check# o7/a� Rec rved By:(/-'/ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />