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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR4-'/yam <br /> fH /►/i/ � /��sQu�� ���/ �' CHECK If BILLING ADDRESS <br /> FACILfrY NAME <br /> SITE ADDRESS 40th /�Vp� ��/ -���� 4S�Yo <br /> Street Number DlreeNon ne,.0 Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> !� o. BoX �79� <br /> Street Number Street Name <br /> CITY STATE /A ZIP <br /> PHONE#1 9 �_��-F EM Das-gra-, LAND USE JAPPUCATION# /✓ <br /> - l3- <br /> PNONE#2 Em SOS DISTRICT O LOCATION CODE <br /> ( ) 95 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /�-^ J' = <br /> /T'/riI/GLG CHECK IT BILLING ADDRESS <br /> BUSINESS NAME / /yr PX n Et* <br /> /� Ay <br /> HOME Or MAILING ADDRESS ` FAX# <br /> �I. Bor o2/fia 620.;) <br /> CIT' J _ + STATE ZIP 47"v C' <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 <br /> or 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,STATE and ZL <br /> APPLICANT'S SIGNATURE: DAVE:[t 7 /D / <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/D AGER ❑ OTHER AUTHORIZEDAGENyt_-I <br /> IfAPPL/CANT is not the BILLING PARTY proof of authorizadon to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> 61511131 R CEIVED <br /> r"e-vr /20/l td851> J U L 1 1 2013 <br /> m•A. <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> ENT <br /> ACCEPTED BY: - EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: PI E-2-6U <br /> Fee Amount: O- Amount Paid oZ�000 Payment Date 7111 13 <br /> Payment Type Invoice# Check# //5�' Received <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />