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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �a coo\Loo 2� <br /> OWNER/OPERATOR <br /> 115=9YnaeRCM � ��� �; �� edCgCKIfBILLINGADDRESS <br /> FACILITY NAME An-1-v s dh nti� �� <br /> SITE ADDRESS i"1 1"l S Un <br /> al 4 <br /> Street Number Direction <br /> Zip Code!� <br /> HOME or MAILING ADDRESS (If Different from Site Address) Z 3-3Z C'- <br /> StreetNumber t w V 1 Street Name <br /> CITY —Vy na STATE^^ ZIP <br /> PHONE#1 t 1 LV` ExT. APN# LAND USE APPLICATION# <br /> (M) 321 -1A g <br /> PHONE#2 EXT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR -t^l.^\ 1 n V vin � /I I I C �Q4 <br /> lr CHECK If BILLING ADDRESS <br /> BUSINESS NNA�MMEE� /�_ 1_.—�I � ` , n^^n P O � _0,3 <br /> ,r � ExT. <br /> HOM� -:" LArD}DyR`ETS1 1 vvu �`'1(/\ vW• `.Y` FAx# '/, <br /> CITY —'l"1Z7 STATE 12-411- 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 d EDERAL laws. <br /> APPLICANT'S SIGNATOR- DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICAN IS Of the BILLING PARTY,proof Of authorization to sign is required 7'ille <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 /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It'Is available and at the same time it Is provl4led t0 me Or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: "� �VLI G�k �� Q�FvG� <br /> COMMENTS: <br /> s NJo`q(p.�?� ?018 <br /> h YD 4, ou <br /> ME <br /> ACCEPTED BY: EMPLOYEE#: DATE: 12— <br /> ASSIGNED TO: _ 1, Q� EMPLOYEE#: DATE: `2 <br /> Date Service Completed (if already completed): SERVICE CODE: O P/E: �C) <br /> Fee Amount: �S2 Amount Pal /5�,dD I Payment Date <br /> Payment Type / Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />