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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gomel/ /E L/ IL'� 7"l� 19 2i=u7-)!?J <br /> OWNERIOPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME 7/_// 1A!oVo <br /> SITE ADDRESS / YsE�� /C 14Ll,! — <br /> Z/( Street Number I Direction !p * cetreet Name CI Zip Cade <br /> HOME Or MAILING ADDRESS (if Different from Site Address) ��¢.�y/(� '"jE� � <br /> 2 sveet Number Street Name <br /> CITY r�U STATE ^ ,1 ZIP <br /> PHONE#1ET' APN# LAND USE APPLICATION# <br /> I ) ZS- /6 C 20570 1 / -o/7' 2 <br /> PHONE#2 E%r. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORO t 2/ 11 ) 2 1 1 n <br /> rim �/�• ti•/yK- CHECK if BILLING ADDRESS <br /> BUSINESS NAME Q X�+� /�L�y� • PHONE#�O 54-o <br /> HOME Or MAILING ADDRESSe67 Poe-/TTG 5,44/4 (AX# )3O SI5 -0 - 5,Z4/ <br /> CITY �- { / . ./5 L-O 2l STATE ZIP1 2 A_ <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 /> also certify that I have prepared this Ippat! and that the o It o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes, Standards, FEDERAL law . <br /> APPLICANT'S SIGNATURE: DATE:: P IL d Fol 7 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I ANAGER ❑ HER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof Of authordaf%on t0 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 /> t0 the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT a5 SOOn a5 It IS available and at She Same time It i provided to me Or <br /> my representative. IAA V. <br /> TYPE OF SERVICE REQUESTED: I e•71 <br /> COMMENTS: Ap/? 1 <br /> NJO 9 ?017 <br /> FNIr gQU/N <br /> HE9<TyAepMU N�Y <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: 9( <br /> Date Service Completed (if already completed): SERVICE CODE: �3 PIE: 1 d <br /> Fee Amount: 41- Amount PaqP LH ^D� Payment Date Q <br /> Payment Type Invoice# Check# I ZS y I Recei ed By <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> 07/17/08 <br />