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SAN JOAQLNry COUNTY ENVIRONMENTAL HEALTH L r-PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rJeCA) (�>i2Cb-2-7259 B <br /> OW RI OPERATO <br /> .� CHECK If BILLING ADDRESS <br /> FACILITY NAME I . ' 1 � I <br /> I �1 lAll� <br /> SITE ADDRESS � <br /> Street Number Direction Stre¢t Nam¢ CI ZI Cotle <br /> HOME Or MAILI G,ADDRESS (If Different from Site Address) �Q�i(�n <br /> Street Number 'J-C- Street Name <br /> CITY STATE ZIP <br /> PHONE#'I EXT' TAPIR# LAND USE APPLICATION# <br /> 4aR) a ass I ►e. oq U I `a- <br /> PHONE#2 EXT. BIDS DISTRIC LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRES <br /> BUSINESS NAMEPHONE# EXT. <br /> o C! <br /> HOME or MAILING ADDRESS FAX# <br /> CITY ^ STATE /r w. ZIP <br /> BILLING ACKNOWLE'D`GEMENT: 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�U p` F� k S a�S . DATE: '7 7 <br /> PROPERTY/BUSINESS OWNER riI OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT its 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 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 provided to me Or <br /> my representative. <br /> 1� Y Y L IrY <br /> TYPE OF SERVICE REQUESTED: EDOld <br /> COMMENTS: <br /> bc� #i q�j x 1�3 JUL 11 2011 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: i-y, EMPLOYEE#: DATE: -7 , _ ) '-7 <br /> ASSIGNED TO: vl EMPLOYEE#: DATE: %1/ <br /> Date Service Completed (if already completed): SERNCE CODE: .,O% PIE: <br /> Fee Amount: Amount Paid l S� Cw Payment Date <br /> Payment Type Cet Sj1 Invoice# Check# Received By:1-C--1- <br /> EHD 48-02-025 _ SR FORM(Golden Rod) <br /> 07/17/08 <br />