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J <br /> SAN JOAQUIN L OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property f-A X FV- 0 SERVICE REQUEST# <br /> U\ ` /�Ii� rCI V 5200S0`�D <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NA /S <br /> SITE ADDRESSC ' I n ( O r C 1_ _ St G ��' <br /> C c n G4 5 Zo� ' <br /> 111 -7 Street Number Direction v Street.NNaamee Ci ZI Cotle <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> C v- Street Number Street Name <br /> CITY STATE ZIP <br /> <f n c ct z <br /> PHONE#tAPN# LAND USE APPLICATION It <br /> (j�50 - 6bq - G4Gr-jExT' <br /> PHONE#2 EXT. BQS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> G A V CHECK If BILLING ADDRESS <br /> EAr4CAV '6r(,P-BUSINESS N ME I �( PHONE# EXT. <br /> �S <br /> HOME or MAILING ADDRESS FAX# <br /> G o Creek r ( ) <br /> CITY QC on <br /> ` STATE ZIP 9S7Z- <br /> BILLING ACKNOWLEDGEM,ENT: 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 /> 1 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 a d D L laws. <br /> APPLICANT'S SIGNATURE: DATE: 4- <br /> PROPERTY I BUSINESS OWNER OPERA R/MANAGER ❑ OTHER AUTHORIZED AGENT ❑��J//[�� <br /> If APPLICAN 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 environmental/site asse formation <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It �'pt(iepr <br /> my representative. (+ ••` <br /> TYPE OF SERVICE REQUESTED: 44d I(MACA0 <br /> COMMENTS: O� <br /> 019 <br /> RI N COON <br /> HFAL7)y0 PqR M�n' <br /> ACCEPTED BY: EMPLOYEE#: DATE: 3 / <br /> ASSIGNED TO: 1 yr ✓ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: 3 <br /> Fee Amount: Amount Paid (, OZ) Payment Date 3 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />