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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUE T# <br /> M(-m6CA�Vre t /� is�r bu�o� 5 <br /> OWNER/OPERATOR /�-T-E G� R <br /> K/� 1`T�r .}.� CHECK If BILLING ADDRESS <br /> EI <br /> FACILITY NAME NEI BUT-L Sl S tY <br /> SITE ADDRESS "2-301 C PARA 1 S O 1 R C 930 <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Sit Address) r� <br /> 5,0\ <br /> {� S Street Number Street Name( <br /> CITY -f�CA C STATE ZIP <br /> PHONE#11 EXT. APN# LAND USE APPLICATION# <br /> (3g 5)- 6o2- 66 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR PA-TEL / D16-T PACSFZC RUSL ERS <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME e�IGi-- I) PACT`-.0 I�UTI_��ClS PHONE# EXT. <br /> 3q is 01 <br /> HOME or MAILING ADDRESS 61"0 one r 9e u OC.I 0 FAX# <br /> CITY PLEASANToN STATE CA ZIP (1t,55;q <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,STATS and FED AL laws. <br /> : // <br /> APPLICANT'S SIGNATURE :Dhr U V DATE: 03 — (5 - t1.9 <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT El • E B2 G1 -3) <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 providAIIQme or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 141? / O <br /> 5 <br /> v,01 24 <br /> y FI yb9Rp USN 19 <br /> CO <br /> �lTNO pAR�F <br /> N <br /> ACCEPTED BY: EMPLOYEE#: /j DATE: 5 I <br /> ASSIGNED TO: an rl EMPLOYEE#: dd5 DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: J P I E: <br /> Fee Amount: Amount Pat ��� Payment Date <br /> i <br /> Payment Type Invoice# Check# 2pz2 ecei ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />