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SAN_ JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST#, <br /> 6022 2 SfZOC� �� <br /> OWNER/OPERATOR <br /> ������ <br /> �/ CHECK If BILLING ADDRESS <br /> FACILITY NAME -0 <br /> e 7` JCe <br /> SITE ADDRESS Z <br /> Z <br /> Street N ber Direction Street Name U.)QA'�Sct 11�'se'(�o k Zip o�� <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> pp Street Number Street Name <br /> CITY )Gtit/L^C/ STATE ZIP <br /> PHONE#1 'EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �.^ �� �,� CHECK If BILLING AOORESSO <br /> BUSINESS NAME l'./ PHONE# EXT. <br /> r® " is F-3 15A <br /> HOME or MAILING ADDRESS FAX# <br /> ,P 2 v ( ) <br /> CITY 'V 0.N C - STATE 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 and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: Moy-C0 5 L9 ?e 7 DATE: ( - <br /> PROPERTY/BUSINESS OWNER C3 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br /> If APPLICANT is not the BILLING PARTY.proof Of authorization f0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMAT16N: 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 i orm�a�tio^n - <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the Same time It Is providlyA Jzrp <br /> my representative. nr� ,� <br /> TYPE OF SERVICE REQUESTED: VQIk I I�, T- 1 <br /> COMMENTS: JO /C <br /> N��Th o�M�� (tIV <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: a (� )`(� EMPLOYEE#: DATE: bf Gv1L r,I,,(O <br /> Date Service Completed (if already completedd)):I SERVICE CODE: SLD(o PIE: J[pn <br /> Fee Amount: Amount Paid 13�d� Payment Date �// <br /> Payment TypeInvoice# Check# Received Byljlz)-� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />