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SAN JOAQUSFOUNTY ENVIRONMENTAL HEALTIDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR ,p <br /> 14o,e/ar,4 d( o r n <br /> L/ C CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 909s ^/ Rio 5/6nco 9d. k�—on 9S2/ 9 <br /> Street Number I Direction Street Name 1 71.Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) EI ED <br /> a <br /> Street Number Street Name <br /> CITY STATE zip 'W" 0, r, 17 <br /> PHONE#1 EXT. APN# Q 66QS05'Z LAND USE APPLICATION# NVIRONMENT <br /> I ) 06605"03 PERMIT/ � "B <br /> 7 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> GLV CHECK If BILLING ADDRESS <br /> BUSINESS NAME IIJJ PHONE# ExT. <br /> 101Es FnV/run r,er, 4a In 4/5 M-/600 246 <br /> HOME Or MAILING ADDRESS FAX# <br /> 6 s eed o 5/yd, 3,4t. 2GO (415 ) 899- /bol <br /> CITY IX--�O STATE CA <br /> zip 9y7ys <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 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 laws. <br /> APPLICANT'S SIGNATURE: o DATE: r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER 136HIER AUTHORIZED AGENT M5'1,or S 4C F <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 /> to 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: /Ton, �o J r,n T l/a �t O n , /" 7L/o <br /> COMMENTS: <br /> ,P& kafe or Mo,, �an:.s w2// r',15 L-# A. perm,' + Off /, Gafion 5en4- ILO <br /> K,-4-A C,�e_r_K ' P/east ca// C4/s) '197- 2736 <br /> ACCEPTED BY: T EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />