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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ` 5 _00 ��I- q <br /> OWNER/OPERATOR ,1 <br /> NII1 f-�o�,�� /��� CHECK If BILLING ADDRESS <br /> FACILITY NAME L��4 ( r J <br /> SITEgss I <br /> Street Number D rection 5 reel Name city ZI Code <br /> HOME or MAILING ADDR SS Different from Site Address) P-./1✓1 <br /> ��//}�o�(0 Street Number Street Name ,{ <br /> Cl" f r vJ h„ STATE C j� ZIP 937D*77DT <br /> PHONE#1 ,W EXT' APN# LAND USE APP (CATION# RJ—`�J,) )_C <br /> �9) 43Z-S�Ioo 2� o <br /> PHONE#2 Ex. BOS DISTRICT ' LOCATION CODE <br /> I ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` 65?/0 ' I� <br /> /j C,, CHECK IfBILLING ADORESSE] <br /> BUSINESS NAME -- II GJ^ PHONE Ear. <br /> S; �YIC� V'7 6 L —ZTJ"L I <br /> HOME or MAILING ADDRESS FAX# <br /> 1 Lvrx� <br /> CITY 06 ik, STATE ZIP It <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 /> also certify that I have prepared this applicatJFE <br /> hat t work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards,STATE aAAPPLICANT'S SIGNATURE: � DATE:/ <br /> /� <br /> PROPERTY I BUSINESS OWNER 1:1 OP RATOR/MANAGER 11OTHER AUTHORIZED AGENT LJ ///y/YtD C— <br /> If APPLICANT IS not the BILLING PARTY,proof of authorization to Sign IS required Title <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 to me or <br /> my representative. " <br /> TYPE OF SERVICE REQUESTED: '� ,�O / 0"J PRL <br /> COMMENTS: � T <br /> l2 ��it-6b° GLl lti(J�� NOV 0 3 T� <br /> SgN�O6 <br /> AO <br /> ACCEPTED BY: 1 EMPLOYEE#: DATE: _q- H MEryrq IV <br /> ASSIGNED TO: f' EMPLOYEE#: DATE: T' <br /> Date Service Completed (if alreadycompletd): SERVICE CODE: s7j PIE O <br /> Fee Amount: A Z - Amount Paid�};>�-�`�� /', i� Payment ate <br /> Payment Type j Invoice At Check# ;, _� Received By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />