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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property f � v <br /> 1 �AfJIJ9 REQUEST#�q� S2o� <br /> 9 <br /> OWNER/OPERATOR <br /> 6� � CHECK if BILLING ADDRESS O <br /> FACILITY NAME (� ` ` N <br /> V' _l/��� <br /> SITE ADDRESS \7'la'1 � ( SGP <br /> J t M+� �-L�'� <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) h <br /> F' A <br /> Street Number Street�Name <br /> CITY STATEJP _ <br /> h-t GYJ PSTC� (174Pir 3 <br /> syj- <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (.2&1) S`{eI - SZv(--- <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR ✓ <br /> REQUESTOR S1 Fk�7 <br /> L G S���j`L� l ����,� ��� CHECK if BILLING ADDRESS <br /> BUSINESS NAME1 C S�/w S PHONE# EXT. <br /> HOME Or MAILING ADDRESS FAX# <br /> 3�k 1 I`[ . �-e-Lht f e leu (S;i) 4 4 C-(- c 7 3S <br /> CITY Fr S to G STATE e-/\ ZIP Ct 3'-7 <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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,ST TE and F ERAL Iaws. <br /> APPLICANT'S SIGNATURE: DATE: �� t <br /> PROPERTY/BUSINESSOwNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAGENT9 <br /> UAPPLIC4NT 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 <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: C I S I Ft- f NI E NT <br /> COMMENTS: RECEIVED <br /> MAR Z 3 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 3 Z <br /> ASSIGNED TO r EMPLOYEE#: 2 DATE: I <br /> Date Service dompleted (if already completed): SERVICE CODE: ' C P I E:Z3Z <br /> Fee Amount: -3 ` Amount Paid _ Payment Date 31 -2,3/ L <br /> Payment Type ✓ Invoice# Check# J I v0 Z Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />