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0( " 4 SAN JOAQUI.a COUNTY ENVIRONMENTAL HEALTH MOARTMENT <br />1-171 <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />kA 000 a s 19 <br />SERVICE REQUEST # <br />I sp_.-73 q cl <br />OWNER/OPERATOR n rlr /� ,t <br />Cj 4 //L�. <br />JC <br />CHECK It BILLING ADDRESS� <br />n,^oJ(li�/ <br />FACILITY NAME 0i NQt I Rrt��E <br />HOME Or MAILING ADDRESS ,r 0 0 / -' <br />(p /(� <br />SITE ADDRESS 591.r� <br />Street Number <br />Oir¢ction <br />Aexc idreci P1 <br />Str¢et Name <br />STATE 6*zip GY S� G - <br />/ J <br />JOn <br />CI <br />Ti Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />EMPLOYEE #: <br />Street Name <br />CITY STATE <br />zip <br />PHONE #1 EXT' <br />( ) <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />( ) <br />SOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR I <br />REQl1ESTDR Fe l( NusI <br />4�- j'"'(r�j I <br />l CHECK If BILLING ADDRESS <br />Wlk �l'n <br />BUSINESS NAME O <br />D t�t.� <br />ft J <br />c / <br />i,/t� <br />�� �l�s! C �,r'� <br />PHONE# / p EXT' <br />l9 2- (Y3 <br />HOME Or MAILING ADDRESS ,r 0 0 / -' <br />(p /(� <br />��i� e /I /, <br />" •I �Jt V1 <br />PAX# ) <br />CITY r O A <br />STATE 6*zip GY S� G - <br />/ J <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, TA d FEDERAL laws. C� / <br />APPLICANT'S SIGNATURE: 41 /�t� DATE: <br />c.Il —//I -/ S-yµ�-n.,,-- <br />If <br />_ <br />PROPERTY / BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHERAUTHORIZED AGENT'm �C�r"t 1 I qtr / h MC/ <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 assessment information <br />to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It is available and at the same time it is provid�j r o Or <br />my representative. ENc <br />TYPE OF SERVICE REQUESTED: % + CD <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />15 <br />UN71' <br />L <br />ENT <br />COMMENTS: ���/`n//� r <br />/ 4 .�L(41 �� <br />0 <br />/ � <br />SEP I 6 <br />Sq ENVgQUIE C <br />NEALTryp� ART <br />ACCEPTED BY: <br />7 <br />EMPLOYEE#: <br />ASSIGNED TO: —�n ,./,, <br />EMPLOYEE #: <br />JATE: <br />: 16 <br />Date Service -Completed (if already completed): <br />SERVICE CODE: <br />P/ E: n <br />��o o� <br />Fee Amount: „�%' <br />Amount Paid`ra�O.aD <br />Payment Date <br />`i /S��,(��� <br />Payment Type I <br />Invoice # <br />Check # 9-742-3 <br />Received By: 666 <br />EHD 48-02-025 SR FORM (Golden Rod) <br />07/17/08 <br />15 <br />UN71' <br />L <br />ENT <br />