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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DILPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS 1 r ,,� r�^U I <br /> 1 1 OD Street Number Direction Q-�!""v""SNeet-�ame "'"—'F O ' Z( Catle <br /> HOME Or MAILING ADD R SS (If ifferent from Site Address) /� v <br /> —T <br /> l Street Number "SFreet Name <br /> 41 <br /> CITY TATE �P�-82 <br /> 1:s/SCE2-SME <br /> PHONE#t EXT. APN# LAND USE APPLICATION# <br /> tiilb) 4ZD • (moo <br /> PHONE#2 EXT. BCS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR f <br /> 1 CHECK If BILLING ADDRESS <br /> BUSINESS NAME PONE# ExT. <br /> ` r (p�o'b <br /> HOME or MAILING ADOREFAX# <br /> 1 o E ��lE ( ) <br /> CITY ,,, /�� ,� sn STATE n ZIP C tr^CO <br /> BILLING ACK—NOW3.LEDGEMEN : I, the undersigned property or business owner, operator or authorized agentofsame, <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 tat the rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,I 7aFEDE: <br /> L laws. ^ <br /> APPLICANT'S SIGNATU�RE:/ - - J DATE: 1 • Z� (S <br /> PROPERTY/BUSINESS OWNE$�J^ 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, 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 assessmentinformation <br /> to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time It Is QKI{�y�gyme or <br /> my representative. <br /> TYPE OF SERVICE REQUESTED: C / R r <br /> 1 11 n'- <br /> COMMENTS: Ju` % �A LV <br /> 01141" <br /> SH�N�p00 pAROJopoil ME T <br /> ACCEPTED BY: EMPLOYEE#: DATE: ' <br /> it <br /> ASSIGNED TO: �- EMPLOYEE M DATE: ' / <br /> Date Service Completed (if already completed): SERViCECODE: 06 PIE: I <br /> Fee Amount: / Amount Paid 13 V r t9 (J Payment Date oZ ` <br /> Payment Type C/� Invoice# Check# Received By: Kehl <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />