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SAN JOAQUIN t.OUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />if� u CHECK It BILLING ADORES <br />BUSINESS NAME S 7GE. <br />FACILITY ID #:::] <br />PHONE# 73 ExT. <br />6 <br />SERVICE REQUEST # <br />/ ce C e 0- <br />FAX # <br />( ) <br />CITY/' G l <br />STATE /'ifl— ZIP 9 /" Dfi. <br />Si2Cb� X35 <br />OWNER/CIPERATOR <br />CHECK If BILLING ADDRE551� <br />e <br />h <br />r/� <br />FACILITY NAME <br />S )r -O < —o A) [moo N <br />u L. Ice- <br />f <br />ccltcm <br />S TE/AD RES <br />N <br />W e <br />L� <br />�J <br />XJ Street Number <br />Direction <br />S} ► e eri <br />A v���'DI <br />Code <br />HOME Or MAILING ADDRESS (If Different from Sile Address) <br />2 L Y (i ) G V e <br />Street Number <br />Street Name <br />CI IOC TIS <br />f�— <br />STATE ZIP <br />PHONE#1 ExT. <br />2� N30 Z 7 3 <br />APN # <br />-�3[ODZ-1 - <br />LAND USE APPLICATION # <br />PHONE 42 EXT. <br />BQS DISTRICT <br />LOCATION CODE <br />c ) <br />7- <br />b - <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />' � -- ( <br />if� u CHECK It BILLING ADORES <br />BUSINESS NAME S 7GE. <br />- rem <br />PHONE# 73 ExT. <br />6 <br />HOME or MAI G ADD ESS <br />/-1V G nr(cte- <br />AVeJ <br />FAX # <br />( ) <br />CITY/' G l <br />STATE /'ifl— ZIP 9 /" Dfi. <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 />1 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: rZi L DATE: <br />PROPERTY/ BUSINESS OWNER [I OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT ❑ <br />If APPLICANT IS not the BILLING PARTY, proof of authorization to sign Is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. ADI <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: c v• W' ^ Ahp 0 O <br />H�c�� �QNo N 1, <br />r <br />ACCEPTED BY: /i P (VU- ntx.� EMPLOYEE M DATE: <br />n V-1/1 Y Imo' /L;J <br />ASSIGNED TO: (^" EMPLOYEE M DATE: _ 14 /,91/ If <br />Date Service Completed (if already completed): SERVICE CGDE: D to PIE: /to0 2— <br />Fee <br />Fee Amount: I SZ W Amount Pal Sa, OD Payment Date <br />Payment Type Invoice # I Check # I Ri4cei d Byi/ <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />