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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACII-ITY ID# c SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> V <br /> FACILITY/NAME <br /> 109 A tv D Mn Eo 7- T/ON C a/2 <br /> SITE ADDRESS ,?l l /8 5 51-Afa 90KTe 33 I-kgGy 1f3,94 <br /> Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3 3G /f TjC/ <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> a AJ Fa s,rc,S c t7 CA 14 Ye <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (41n 7,03 - ort/0 2mss- io- Z3 Pa - 140003 <br /> PHONE#2 EXT. BOS DISTRICTLOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> Doi! c/�6-5 <br /> �/r ff� CHECK If BILLING ADDRESS <br /> BUSINESS NAME /V `/i JIV G- r PHONE# EXT <br /> CNE6146-Yo uL T n/C 20 (, o-14,93 <br /> HOME or MAILING ADDRESS FAX# <br /> p (zo ) G 60 -l5 90 <br /> CITY u 2L D SIL STATE 0 ZIP S 3 / <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 applic ion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STA d FEDERA <br /> APPLICANT'S SIGNATURE: _ DATE:: Z 3 / <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR 1 M NAGER ❑ O ER AUTHORIZED AGENT <br /> /(APPLICANT is not the BILLING PARTY,proof of authori ation to sign is required Time <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, 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 to me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: /7—&A a LaA p/L fN jrA st L/ E vy E A <br /> COMMENTS: <br /> l ''1 Apt?..2 <br /> Ep <br /> ` SAN JO 2415 <br /> D TAS Ty <br /> ACCEPTED BY: �f` EMPLOYEE#: DATE: <br /> 1 vr <br /> ASSIGNED TO: CN d c EMPLOYEE#: DATE: (f <br /> Date Service Completed (if already completed): SERVICE CODE: "� IPI E: 2�0 <br /> Fee Amount: c�' I T,Amount Paid �Sv (�� Payment Date <br /> 23 <br /> Payment Type Invoice# Check# 3 3 Recelled By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />