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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> L too <br /> Z t0 <br /> OWNER/OPERATOR Y�1' CLA^ ' N f `Q- r� <br /> / a tnn � IL. `�' (�,y f�1 �2v`t��� ALL CHECK if BILLING ADDRESS <br /> FACILITY NAME-- 1r_,'',V�4V C , ! <br /> SITE ADDRESS 1 �'1 � _��' <br /> IZ�S Street Number Direction I Street Name , city Zip Code <br /> HO�MLE for AILING PADDRtE/SSS (�f/DI�Ip/e�rrennt�f^r•�t(�,Sit�ddresss/)� //�� ` n Ile— <br /> V`99 'G1`YC"-`�• ^'—�^+ • `-^� ,A-�/7—Street Number F � Street Name <br /> CITY �^ �r yl f ,p st ZIP ��/ <br /> PPHONEE tt lJ ` •1- E%T APN# LAAND/USS'E'APPLICATION# (..'l� <br /> PHONE#2 �T• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \'I <br /> 1,..e .1t CHECK If BILLING ADDRESS <br /> BUSINESS NAM'�S b �/� 1 /'Gl��\. � # t-2 r7 <br /> ME 9rJJ0pl�lylG ADD[tES i i,r,r��vllll(�- X# I /—,SV <br /> CITYI L�/lam- r O,^IC Irl 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 ct specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or usin s as identified on this form. <br /> I also certify that I have prep red t s a plic ' ftFEDEI <br /> ork to be performed will be done in acco ince with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Sta and , S Ar <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY I BUSINESS OWNER❑ ERATOR I MANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of auttro ation 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 environmentallsite assessment information <br /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 soon as It IS available and at the same time it Is.proVjded to me or <br /> my representative. 1n,-, <br /> TYPE OF SERVICE REQUESTED: NQ,�AI 5 h P hir\ CW-(k- <br /> COMMENTS: <br /> Ec T <br /> COMMENTS: D <br /> Jut 11 10 <br /> ////n���� o �EIJ OAQUI N OOU <br /> \ v I �� C �% �� L HEALTH pEN E N <br /> T ' q T <br /> ACCEPTED BY: m `�� EMPLOYEE#: DATE: " F <br /> ASSIGNED TO: J EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 'J.2-3 PIE: 3(00 1 <br /> Fee Amount: �Q�p v Amount Pal dg 0� Payment Date 712.2-11 <br /> Payment Type y w 1 <br /> Invoice# Check# 17461 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />