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SAN JOAQUIN UOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE(QUEQST# <br /> OWNER/ OPERATOR , <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 237001 23quo iiMt t-nN 2375"7 Copy&weL/j Xo. &fvoa' 452,71(. <br /> Street Number Direction Street Name CRY Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 7J o <br /> G' Street Number Street Name <br /> CITY STATE , ZIP ry S 2 3 <br /> PHONE#1 Ext. APN# &W3—12,.) Ob rOO,tsl LAND USE APPLICATION# <br /> (W ) 1?0 2 <br /> PHONE#2 Err, BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS O <br /> BUSINESS NAME PHONE# Exr• <br /> ( 7 0 ) `rt _66 /3 <br /> HOME or MAILING ADDRESSFA%# <br /> F- 0. f� K 2i -0 ( 2rr/1 33`/- o7ZT <br /> CITY �I�; STATE 5* ZIP —2 u <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. n <br /> APPLICANT'S SIGNATURE: /` 1��, DATE: ( 7-0 — 07 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I NLkNAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PARTY proofofauthorization 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 /> COMMENTS: ///p/o, 5sut R.yw„✓���o.,,em) RECEIVED <br /> f'� -7 <br /> y/ 3 SEP 2 0 2007 <br /> SAENVIAQUIN COUNTY <br /> VIRONMENTAL <br /> "PAIXN DEE <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> 7 . <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: U^ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 ".5R FORM(Golden'Rod) <br /> REVISED 11/1712003 <br />