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SAN JOAQUIN GOUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />TA svk"I& — K -Www c %AK14-U3 <br />FACILITY ID # <br />PHONE# v ��� EXT. <br />SERVICE REQUEST # <br />l k 00 7& Y V(o <br />OWNER I OPERATOR (" VAV E ,(� t� C, <br />rf� C' vv V V <br />CHECK if BILLING ADDRESS 0 <br />FACILITY NAME V ` Vl 1 1 06S-SSLp <br />(�NIWWE <br />H, �RpH�N <br />SITE ADLD�RESS PPc kv' C, <br />We:- x3 <br />��,jC� c,4e'ISZa �- <br />23 `, Street Number Ire on <br />Stree Nama <br />CI <br />HOME Or MAILING ADDRESS (if Different from Site Address) <br />!�L <br />Street Number <br />Street Name <br />�p <br />CITY VI� CZIJ� <br />DATE: Z / <br />� zIP <br />SCjT-' 6A <br />PHONE #1 EXT. <br />t51'D Q��- 32 <br />APN # <br />DATE: i 2 <br />T <br />LAND USE APPLICATION # <br />PHONE #2 EXT' <br />t ) <br />SERVICE CODE: <br />BOS DISTRICT LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REWUESTOR �„[- 1� V ��+ S ^ �-G, {+�n'� CHECK if BILLING ADDRESS <br />` <br />�11 �C�S�SS�O cj�l�1�`W� Vl <br />BUSINESS NAME <br />PHONE# v ��� EXT. <br />HOME Or MAILING ADDRESS �.11 �G �(�, v <br />Fax # <br />CITY STATE C i Zip CA S <br />BILLING ACKNOWLEDGEMENT: 1, 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, STATEa EOE s / <br />APPLICANT'S SIGNATURE: DATE: O 3 1 1 <br />PROPERTY I BUSINESS OWNEROPERATO / 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 infornppAwatio�n <br />t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the Same time it is provided to/W!i_ <br />my representative. 1 jj-� ss ]� A% ���^11 rrr���r <br />TYPE OF SERVICE REQUESTED: ?—,-YA iA ;� (— 7` CO 11 r--, L, (7 A T 16f) w_ �V&;' <br />COMMENTS: <br />Q rJ <br />H, �RpH�N <br />Ty�� <br />ACCEPTED BY' <br />EMPLOYEE#: Ti : <br />DATE: Z / <br />ASSIGNED TO: -rG <br />EMPLOYEE #: 'I (p LZ� <br />G <br />DATE: i 2 <br />T <br />Date Service Completed (if already completed): <br />SERVICE CODE: <br />PIE: V <br />Fee Amount: M60 <br />Amount P <br />3 00 <br />Payment Date <br />7 <br />Payment Type <br />Invoice # <br />Check # 77 7 <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />4 <br />ENT <br />