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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P-L)00 )- I )- <br /> OWNER/ <br /> - <br /> OWNER/OPERATOR `3� /1 � 1 I <br /> /J 1` Il CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 60 <br /> [QP—P � !�>/���I ✓� lql� ' �)l <br /> Street Number Direction Street Name L CI Zip Code <br /> HOME,Or MAILING ADDRESS (If Differen om Site Address) <br /> �V ` � %C�`a Street Number Street Name <br /> CITY 0 CLJP 61'�IP�t)5 <br /> PHONE#11 l �^ E? APN# LAND USE APPLICATION# <br /> PHO E#2 ^ 404 <br /> I 0 1 �& BOS DISTRICT LOCATION CODE <br /> 111. <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR J <br /> V CHECK if BILLING ADDRESS <br /> BUSINESS NAME ^ PHONE# EXT. <br /> (L 51 v <br /> HOME Or MAILING ADDRESS�4�� ��� /� �1 (AX# ) <br /> CITY k /I � �\ /� TATE ZIP <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, STATE and FEDERAL I2W�Sy <br /> APPLICANT'S SIGNATURE: ,3 (./��_���—�, DATE: <br /> /:2— <br /> PROPERTY/BUSINESS OWNER❑ 9 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <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 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 t0 me or <br /> my representative. 1 <br /> e.�,ki <br /> TYPE OF SERVICE REQUESTED: {] <br /> COMMENTS: 1 Wa V GLV/ <br /> SAN JOAQUIN COUNT`- <br /> t{EEANCNMENTAL <br /> L7H DEPARIR TMENT. <br /> ACCEPTED BY: n V EMPLOYEE M DATE: <br /> ASSIGNED TO: L ` yA rA r EMPLOYEE#: DATE: �012- 1 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: �1 <br /> Fee Amount: ;� 2 . U Amount Paid I e� Payment Date I <br /> Payment Type �� Invoice# Check# Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />