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SAN JOAQt, OUNTY ENVIRONMENTAL HEALTH ,PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Isco o l e 1, SA6 0 9 / 13 <br /> OWNER/OPERATOR / QT© CHECK if BILLING ADDRESS❑ <br /> 3-C>L G I nU� ici/1� {�SSoG /I <br /> FACILITY NAME C <br /> SITE ADDRESS <br /> 3 550 L4005be, Direction Street Name Ci Zip Code <br /> HOME or MAILING AD RESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> ( ) dJ i)0Z <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> -A <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR 1 z —C (4 <br /> REQUESTOR <br /> /D r�yC /f �- CHECK If BILLING ADDRESS <br /> BUSINESS NAME r C �/ PHONE# EXT. <br /> C0nS uG , oma 6/ 2 - <br /> HOME or MAILING ADDRESSFAX# <br /> ,2L4 ,S-- P017 117 1 ) <br /> r <br /> /-.t e /—C, --- STATE /'�� ZIP Y S <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 SIGNATUREv����'�—� \ DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT , �o/I Ti^--c c-7-e) <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 environ m nt I/ ite s e Information <br /> rLr <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It IS available and at th t e I d� rt V X641 me Or <br /> my representative. , ' <br /> TYPE OF SERVICE REQUESTED: A <br /> COMMENTS: _s. <br /> , <br /> -N <br /> E N PJi E N �I.`��L <br /> SAN`BOAAR 1 p z��RMITI <br /> N� jQUI <br /> CTy RON'FNTUN� <br /> ACCEPTED BY: EMPLOYEE M �rvrME DATE: Z Z G C <br /> ASSIGNED TO: EMPLOYEE#: c DATE: 7 /216 /?_0 <br /> Date Service Completed (if already completed): SERVICE CODE: 523 P/E: 2 O 1 <br /> Fee Amount: 3o t.f Amount Paid Payment Date —z— 2-1 2,0 W <br /> Payment Type Invoice# Check# CC er Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />