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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />ii4e,8/z_ rz7c,i6 <br />FACILITY ID # SERVICE REQUEST # , gze) ( f .6 , c( I <br />OWNER / OPE_WORJ <br />le _.6.' 5.{:{-P CHECK if BILLING ADDRESS 0 <br />FACILITY NAME A th r 8 Ili F 0157 - <br />SITE ADDRESS <br />op I Street Number <br />5 <br />Direction <br />,5-- 4 i,e 0 hi z.±.-N-FtY <br />Street Name <br />C4 <br />City <br />S.,111-e <br />Zip Code <br />HOME Of MAILING ADDRESS (If Different from Site Address) <br /> F4 • 3 Street Number <br />4 IZ <br />Street Name <br />CITY STATEii ZIP <br />,` te Orrev1/ (.77 5 ST,2 42-- <br />PHONE #1 EXT. <br />Oil .? <br />- APN # LAND USE APPLICATION # <br />PHONE #2 Exr. <br />( ) <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR CHECK if BILLING ADDRESS <br />BUSINESS NAME PHONE # <br />( ) <br />EXT <br />HOME or MAILING ADDRESS FAX # <br />( 1 <br />CITY 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 <br />or 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 F -DERAI aws. <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER 0 OPE OR / MANAGER 0 OTHER AuTHORizED AGENT 0 <br />If-APPLICANT is not the BILLING PARTY proof of authorization to sign is required <br />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 environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTI I 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: FO 0 sb ki e i-o CL E__ 0A-k..(' Pe c• 77 0 ") <br />PAYMENT <br />COMMENTS: RECEIVED <br />DEC 1 9 2011 <br />SAN JOAQUN COUNTY <br />ENVIRONMENTAL <br />HEALTH D EPARTN Eta' <br />ACCEPTED BY: 0 ct UC (:. f(2A EMPLOYEE #: 03 .2.4 DATE: / ( //// <br />ASSIGNED TO: p_A.....vc( t 2 EMPLOYEE #: i 0 ?_ (-1 DATE: i if ci /(t <br />Date Service Completed (if already completed): SERVICE CODE: ( 6: i P I E: <br />Fee Amount: 4 1 L Amount I Amount Paid Payment Date <br />Payment Type Invoice # Check # Received By: <br />EHD 48-02-025 <br />SR FORM (Golden Rod) <br />REVISED 11/17/2003