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SAN .JOAQU... COUNTY ENVIRONMENTAL HEALTH #ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property -J-r� o FACILITY ID#D SERVICE RIE # <br /> OWNER I OPERATOR p� U47j/J, 6 <br /> ea G CHECK If BILLING ADDRESS <br /> L i <br /> FACILITY NAME pT"h' <br /> V f C) t aye 3 <br /> SITE A/61 58 n /I '/�/g/y 5 <br /> W UJ � <br /> Street Number Direction �I 5[�ecta lmef 1 l.c '� Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> UV e Street Number Street Name <br /> CITY STATE ZIP <br /> .S 0 tl p <br /> P #'i � ExT. APN# LAND USE APPLICATION# <br /> 0 /91 � <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR LS[A S _- <br /> U[f/l CHECK If BILLING ADDRESS <br /> BUSINESS NAME I PHONE# 5 Y, I' ExT. <br /> HOME Or MAILING ADDR SS FAX# iL <br /> IF55 ro Ave, ( ) <br /> CITY SOC <br /> n STATE ZIP 0/6 <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 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 SIGNATURRE::/�P ��S S�. �°r/jG7� DATE: <br /> PROPERTY I BUSINESS OWNER ltd OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required True <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 provi ed to me or <br /> my representative. �r <br /> TYPE OF SERVICE REQUESTED: v tAl l V <br /> COMMENTS: fC�•e 0, <br /> cry O uM trShiey^, r,Gl ?019 <br /> ACCEPTED BY: S EMPLOYEE#: DATE: Ln <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O I PIE: I(V603 <br /> Fee Amount: ,CT .0 Amount Pai /s� by Payment Date <br /> Payment Type ✓ Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> 07/17/08 <br />