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SAN .JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY7tCK <br /> ID VICE RE U(ES�# <br /> OWNER/OPERATOR U�y�`'if BILLING ADDRESS El <br /> IF ILITv N E <br /> �. Cr3 e cKE v1 Q o wSq�DRESS <br /> 10 W L� 1"StreetNmbHOME Or MAILING ADDRESS (If Different from Site Address) NZi Co <br /> CITY Street N <br /> Street Name <br /> STATE Zip <br /> PHONE#1 ExT• APN# <br /> 009 ) %f?3 LAND USE APPLICATION# <br /> PHONE#2 T EXT. <br /> ( ) BOS DISTRICT LOCATION CODE <br /> REQUESTOR CONTRACTOR/ SERVICE REQUESTOR <br /> /-nr Al/4r E 14� CHECK if BILLING <br /> BUSINESS NA RR 11 <br /> L r r� r I p'�t /�/y 1 l� r PHONE# EXT, <br /> � HOME or MAI G ADDRESS LL <br /> 200 / FAxri 1 <br /> CITY + • ( ) <br /> I� G STATE 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, Standar , ST E nd FEDERAL laws. <br /> APPLICANT'S SIGNATURE: , � ^o�,' 1 <br /> DATE: �v JD -� <br /> PROPERTY/BUSINESS OWNER OPERAT /MANAGER ❑ OTHER AUTHORIZED AGENT J2r (.mob h7r w-#-TO r <br /> IfAPPLiCANT 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. <br /> TYPE OF SERVICE REQUESTED: C' � 4 (V\ awtbiltPAY AAE NT <br /> COMMENTS: r RECEIVED <br /> 1 2018 <br /> :;AN JOAQUIN OUNTY <br /> ENVIRONMI NTAL <br /> EALTH DEPA TMENT <br /> ACCEPTED BY: CSV"raf j 0 EMPLOYEE#: 6LAI 7 DATE: 1IIZr a <br /> ASSIGNED TO: 71 -c&6k (��, EMPLOYEE#: <br /> /0 � DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z P/E: <br /> Fee Amount: ,& Amount Paid Payment Date <br /> Payment Type Invoice# Check# <br /> Received By: <br /> EHD 48-02-025 <br /> 07!17/08 <br /> SR FORM(Golden Rod) <br />