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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> SP-W-7C.61,P9 <br /> OWNER/OPERATOR �+ I 6- <br /> lfJ_µ7+L*X&"U 41% CHECK 1181LLING AD DRESS <br /> FACILITY NAMES (+ <br /> ' SITEADDRESS �I- p 5. CGtI f r0Y-NI LL S 1 <br /> Street Number Direction Street Name Li Zia Code <br /> l HOME or MAILING ADDRESS (If Different from Site Address) 3G` I I t l 0.Y-1 10k* /.-V-1,11- <br /> Street Number Street Name <br /> / CITY �-TO 1. �D� STATE zip SL O 1 <br /> PHONE#1 Eur. APN# LAND USE APPLICATION# 'b <br /> l (3z3) 31-1' '33g3 L703 <br /> PHONE#2 EXT. BOS DISTRICT t LOCATDON CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> !NECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ear. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE- zip <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 /> APPLICANTSSIGNATUR@ y�j ® �y��yu DAT' E: Z Iz— 7% <br /> PROPERTY/BUSINESS OWNER, <br /> OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT Is not the BILLING PARTY proof of authorization r0 Sign IS require!/ 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 assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time it is pr, yided to me or <br /> my representative. ll /I A� <br /> TYPE OF SERVICE REQUESTED: —vp L 0-tA,'G <br /> COMMENTS: SAN JOA QUlry O T 20j� <br /> fry <br /> NfALTN De of TME <br /> ACCEPTED BY: r „t EMPLOYEE#: DATE: <br /> ASSIGNED TO: 6-l_O�r5 � EMPLOYEE#: DATE: T <br /> Date Service Completed (If already completed): SERVICE CODE: , P/E: ( o <br /> Fee Amount: I Amount Pai 30.0 c"�. Payment Date laZ I / <br /> Payment Type 0,467' Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />