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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SF-W7)- 43 <br /> OWNER/OPERATOR <br /> C I �\ �� CHECK If BILLING ADDRESS <br /> minFACILITY NAMES L <br /> G 1J S o L :ice- CF 8 Q YVl <br /> ,SITE ADDRESS �b��Ve- we � F, Avg S'ro��To/�/ 9sala <br /> �79D F'o W Street Number Directlon I Streal Name CI Zip Code <br /> HOME or MAI NG ADDRESS (If Different fro ite Address) aK <br /> Street Number Street Name <br /> CITU1 e S ,/ TATE zI l/`a <br /> PH N 1) I/ EIT. APN# �/ LAND USE APPLICATION# ( <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> G U G CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT' <br /> L ---rG 650 669-HOME or or MAILING ADDRESS FAX# <br /> ego S G O _ / _5 Jr ( ) / <br /> CITY 4aS 9 STATE A/ V ZIPS I D.6 <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, STATE and FEDERAL laws. 7 <br /> APPLICANT'S SIGNATURE: a 0 !/tet on✓GLSN� DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOttttR/MANAGER%TITER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 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 t0 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: C{X1SwI�G �Af r <br /> COMMENTS: o <br /> sAIVjogQu/ ' ?420 <br /> HN CO <br /> ST N Df PSR 7,14 <br /> M NT <br /> ACCEPTED BY: I A EMPLOYEE M DATE: I 119-0 I/t � <br /> ASSIGNED TO: r r l^^ EMPLOYEE#: 3 DATE: II ZU <br /> Date Service Completed (if already completed): SERVICE CODE:✓ D PIE: I W3 <br /> Fee Amount: Amount Paid (��i Payment Date 8/(11 20 <br /> Payment Type / Invvooice# Checkk## Received <br /> EHD 48-02-025 eye#' /— SR FBOyR <br /> M(Golden Rod) <br /> REVISED 11/17/2003 <br />