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SAN JOAQ COUNTY ENVIRONMENTAL HEALTH PARTMENT <br />SERVICE REQUEST <br />Type of Business or Property FACILITY ID # SERVICE REQUEST # <br />RA 9 <br />OWNER 1 OPERATOR j 1 O 6a 73 3 <br />® r v 1 e; Cxecx If BLURLADDS❑ <br />I <br />FACILITY NAME <br />SrreADDr3a:ss <br />Street NumberDimon G ' `✓ � ��.nv1 �S � ��f " J J <br />Street Na CVo Cod <br />HOME Or IUTAII.tiHtG ADDRESS (If Different from Site Address) MMAIVE 4 <br />oftNumbajMidName <br />CITY y� STATE zip <br />1"n 1)7 0 <br />PHONE#iT• APN# <br />LAND USE APpLTCA770N# <br />ENVIRO <br />PHONE 02 EXr. SO$ DISTRICT <br />r7t7Af-1rWrA% <br />CONTRACTOR / SERVICE REQUESTOR <br />REQLIESTOR <br />/C <br />C � i � CHECK if BILLING ADDRESS <br />tf t11� f <br />1 BUSINESS NAME ExT, <br />HOME or MAILING FAX# <br />CITY } q -173,f`_ <br />( C STATE CIO 6 ZIPq ?7 <br />7 7 <br />BILLING ACKNOWLEDGEMENT: 1, 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 to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, STA and FEDERAL I we <br />APPLICARIT"S SIGNATURE: DATE. f o 4AG� <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR 1 MANAGER ❑ OTHER AUTHORIZED AGENT an <br />IfAAPLICANT is not the &umG PARTY proof of authorization to sign is required hate <br />AUTHO#212ATION TO REL INFORMATION: When applicable, 1, 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: <br />COMENTS: <br />Gf i S�.Xrf Wit. k. . <br />ACCEPTED BY: <br />ASSIGNED TO: flCnW�/*y` <br />Date Service Completed (if already ComAleted): <br />Fee Amount:?� Amount Paid <br />Payment Type Invoice # <br />EMPLOYEE#: <br />RECEIVED <br />OC T'2 8 2015 <br />SAN JOAQUIN COUNTY <br />ENNVIROMSWAL <br />HEALTH DEPARTMENT <br />EMPLOYEE #: <br />SERVICE CODE: <br />3 c7 0, C9 Payment Date <br />Check # 661-7 1 <br />DATE: LO 'S; <br />DATE: a f <br />pi r. <br />Received By:,-,_ <br />EHD 48-02-025 <br />07/17/08 SR FORM (Golden Rod) <br />