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( / ) . SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Vu - SERVICE REQUEST <br /> Type of Business or Prop rty FACILITY ID# SERVICE REQUEST# <br /> dpS'� tz: 5i2 <br /> OWNER/OP RATOR <br /> A')uw 1 CHECK ifBILLING ADORE330 <br /> FACILITYHu ME I <br /> w yl"�L <br /> SITE(A(�DDRESS S� <br /> -L'n4v0Z Street Number I Dr tion F2,' Cil Street Name 1 <br /> HOME Or MAILING ADDRESS (If Different from Site Addre <br /> ss <br /> (� ZZ.- `r"�' Street Number Street Name <br /> CITY STAT ZIP <br /> ?s2(S- <br /> PHONE#t En. APN# LANG USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> 'f` CHECK If BILLING ADDRESS <br /> BUSINESS NAME /!moi` C - PHON # (,r' ExT <br /> HOME Or MAILING ADDRESS ) <br /> (` r v FAX# JZ / <br /> CITY t STAT ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all Site and/oI 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, STA a d FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ O TO /MANAGER ❑ OTHER AUTHORIZED AGENT Gj`_ <br /> If APPLICANT is not the ZLING ARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE ATION: 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 environmentaUsite assessment <br /> information t0 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: Zwdulo <br /> COMMENTS: p <br /> y�l q ( CG17�✓ tcTirt/ �uC�D �lsfinCyE T—�tlet�YxCv PAYMENT <br /> h �� T FITC SriG/ O�e l SS RECEIVED <br /> SEP - 1 2009 <br /> ACCEPTS Y: EMPLOYEE#: 3a� DAT�'IOAQUI CQ v. <br /> ASSIGNED TO: EMPLOYEE M DATE: <br /> Date Service Completed (If already completed): SERvtCECODE: �b PlE: �L <br /> Fee Amount: Amount Paid Payment Date <br /> Payment TypeInvolce# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> RF\/IRFn�1H7ronna <br />