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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST It <br /> OWNER/OPERATOR <br /> S O CHECK If BILLING A00RE5S� <br /> yls <br /> FgcILIry NAME l� <br /> -�onn a, _1 <br /> SITEADDRESS Z(pZ(V �I W�-..St Ltd <br /> Street Number Direction Street Name CI Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �/ <br /> V C ? ( ` / , Street Number GGG Street Name /// Ty <br /> Clry K 1� ��f��r (— �T'I ZIP 1 �(l <br /> PH NE#tEXT' APN# LAND USE APPLICATION# <br /> ( Ira) 20,1_ 7 �fv <br /> P Eq 25 �, � EXT• 130S DISTRICT LOCATION CODE <br /> r�f / CONTRACTOR/ SERVICE REQUESTOR <br /> RE UESTOR CHECKIf BILLINGADDRESS13 <br /> Cxo-e't� n of 6 �� Kcc� LLL <br /> v ,.,�--� / C /fExi. <br /> BU ESS Y ' PC�/# <br /> H� r NAIL NG ADDRESS - FA%# <br /> K KCti un C S r Kms. aUU I ( ) <br /> CITY 1/ r ,/,Y$ ATE 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 appRjcation-andl lat the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ATE and FEDERAL la s. <br /> APPLICANT'S SIGNATURE: DATE: 7 (� _ <br /> PROPERTY/BUSINESS OWNER Ea OPERATOR/MANAGER E3--) OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required zitte <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 assessmentinfor on <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It i5 available and at the same time it Is provided to tyhjE <br /> my representative. R 21- <br /> TYPE OF SERVICE REQUESTED: U 'e. (]N114Y 13 <br /> COMMENTS: ' / ?O15 <br /> L I G #_G Y o� 3�J LA I $All <br /> ENV N COUN <br /> HEALT►{ O ENTgL 1Y <br /> EF RTfygN. <br /> ACCEPTED BY; rn EMPLOYEE#: DATE: <br /> ASSIGNED TO: \ �'� EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> I <br /> Fee Amount: I 91�- Amount Paid"�1136.60 Payment Date 6-3//5- <br /> Payment <br /> 5-Payment Type. V1' f Invoice# Chec'Ic# �g'� Received By: <br /> i <br /> EHD 48-02-025 / SR FORM(Golden Rod) <br /> 07/17/08 <br />