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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME ��u �� <br /> Looc �,-� 3.72 L <br /> SITE ADDRESS 1^) t/N ., S S{-11L�C..�^ 9 <br /> Street Number Dlrecllon Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) S5-0,1 L G 5d w I^1S �r <br /> er <br /> -5'5-0'1 rd UM Street NumbStreet Name <br /> CITY `3p-�l 1 STATE ZIP <br /> PHONE#1 Xr/ Exr, APN# LA*N'DT USE APPLICATION# <br /> (�Ov) L1t <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR A H Z-C2 <br /> CHECK If BILLING ADDRESS <br /> ( I� <br /> BUSINESS NAME PHONE# EXT. <br /> C o l q STI �f71 <br /> HOME Or MAILING ADDRESS FAX# <br /> 7,50ACQ I ( ) <br /> CITY L& 1 STATE C-P, ZIP 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �r�'�� DATE: o S1-2-1,t 7 <br /> PROPERTY I BUSINESS OWNERTJyOPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ ' <br /> If APPLICANT is not the BILLING PAR ry 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 asst rttrp. ff�orlr�reation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time I �VIOP�ifl' y Or <br /> my representative. �ffCef <br /> TYPE OF SERVICE REQUESTED: . f �Iph lrjIe <br /> COMMEMS: SAN JOAQUIN <br /> Q c, 1J =' L- ENVIRONMENTAL <br /> COUNTY <br /> LIG37• <br /> � i (t � HEALTH DEPARTMENT <br /> 7 J <br /> ACCEPTED BY: �� / _ EMPLOYEE#: DATE: :5-2D_ 1 <br /> ASSIGNED TO: ' EMPLOYEE#: DATE: ?)- -0 - i'-) <br /> Date Service Completed (if already completed): SERVICE CODE: �: PIE: C)� <br /> Fee Amount: �G r Amount Paitf 16,7,�� Payment Date <br /> 3/2!7// <br /> Payment Type y Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />