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a , , , <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> bo <br /> OWNER I OPERATOR CHECK If BILLING ADDRESS❑ <br /> tU�EI.1� C..aFr=65c <br /> FACWTY NAME ,t <br /> SITE ADDRESS S47Ss ALL OP4 1ZD . STbC-1�•f'[�rJ Cf SZ I S <br /> Street NYmher Direction Street Name Ci 27 Coda <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Numhar Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN• lr6Sy�- 0PA. +T,Ljo LAND USE APPLICATION• <br /> [moi) 463- q' P& /83- Z70-4V,& . P^ - 06-520 <br /> PHoNE 92 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR Mit 7'0-f CHECK H BILLING ADDRESS® <br /> W PHONE Ear' <br /> BUSINESS NAME t1� M,V�[,�Y{-� 3->q-4A-1-5 <br /> HOME or MAILINGADDRESS FAX If <br /> JP•0 • Holt 24&0 ( ) -0.723 <br /> �,, <br /> CITY STATE CA- ZIP 9524- <br /> . <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 <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that 1 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,STATE54 FEDERAL la <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNERD OPERATOR/MANAGER71�1 OTHERAUTHORIZEDAGENT❑ <br /> If APPLICANT is not the BILLING PARTY Proof of authorization 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 environmentallsite 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 /> PAYMENT <br /> TYPE OF SERVICE REQUESTED: <br /> REGECOMMENTS: [ <br /> MAY 0 4 2007 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (If already completed): SERVICE CODE: Z 2� P I E: 6 <br /> Fee Amount: A q() Amount Paid \q'D , �p Payment Date S1 ({ Q1 <br /> Payment Type ✓ Invoice# Check# 1%Lf Z- Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />