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SAN JOAQLOUNTY ENVIRONMENTAL HEALT PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ;)-( Sk 600$ 7 <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME � <br /> �r e LS t,l. ',S (L. I U2 <br /> SITE ADDRESSA)r u..' <br /> j)m <br /> eet uber Direction Street ame Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ,: ) 4 - > / 3- 330-' 6 <br /> PHONE#2 EXT. BOS DISTRICT 2 LOCg ION CODE <br /> ( ) Y <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR / <br /> a1, l 1 t✓� r CHECK If BILLING ADDRESS <br /> BUSINESS NAME "� y ) / ��� 111 PHOONjE EXT. <br /> rtu ( 2 <br /> HOME Or MAILING ADDRESS P,, FAX# <br /> CITY 7 / STATE ZIP C/ E_ <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, T4al FEDERAL laws„ <br /> APPLICANT'S SIGNATURE: -v L � _�- DATE: <br /> PROPERTY/BUSINESS OWNER[3 OPERATOR/MANAGER ❑ `OTHER AUTHORIZED AGENT❑ <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 <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 HEALTH 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: US -t- 12-,E—Nl-6 F [ RECEIVED <br /> COMMENTS: <br /> MAR 17 2009 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: D�V Jet EMPLOYEE#: 3 DATE: 3 f 110 <br /> C <br /> ASSIGNED TO: N 6- EMPLOYEE#: <�'Lt DATE: 07A-7 <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: L3C+F <br /> Fee Amount: 'f 3 !� 6 Amount Paid -6 315-- v 0 Payment Date 3 ? <br /> Payment Type ✓ Invoice# Check# 10S73 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />