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SAN JOAQUIN ( JN'I'Y LNV1ItONML, N'I'AL IIL,AL'I'I TWARTNIENT <br />SERVICE REQUEST <br />Type of Business or Property, <br />nt. <br />CHECK If BILLING ADDRESS <br />FACILITY ID # <br />COMMENTS: <br />SERVICE REQUEST # <br />C as sa-t-� <br />FAX # <br />CITY <br />STATE ZIP <br />OWNER / OPERATOR <br />❑ <br />SAN `�NEP�Sti' <br />CHECK If BILLING ADDRESS <br />FACILITY NAME T►� a c Q t+ N 6 AA hP, T <br />SITE ADD � <br />lJ 'U <br />DATE: /2 \ G <br />ASSIGNED TO:t V 1 <br />- <br />StredN.bl <br />DIrectton <br />Street Name <br />DATE: <br />CIl <br />ZI Code <br />HOME or MAILING ADDRESS (It Different from Site Address) <br />PIE:7jC� <br />Street Number <br />Street Name <br />CITY <br />Amount Paid <br />STATE ZIP <br />PHONE #1 EXT. <br />( ) <br />Payment Date <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />Check # <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SRRVICR REQUESTOR <br />RQUESTOR <br />CHECK If BILLING ADDRESS <br />BUSINESS NAME <br />COMMENTS: <br />PHONE # EXT. <br />HOME or MAILING ADDRESS 1l,, 117 <br />FAX # <br />CITY <br />STATE ZIP <br />_iI3tI,I,ING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMCNTAL HCALTtI DBPARTMGNT 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, STATE and FEDCRAL laws. <br />--��APPLICANT'S SIGNATURE: � DATE: <br />PROPERTY / BUSINESS OWNER ❑ OPGRATORI MANAGER ❑ O r11LTR AUTnoiuzED AGIFNT ❑ <br />If At'PUCANT is not the BILUNG PARTY, proof of authorization to sign is required Tirte <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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, ENVIRONMENTALHCALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to Inc or my representative. <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />R� <br />SAN `�NEP�Sti' <br />APPROVED BY. L <br />EMPLOYEE #: <br />DATE: /2 \ G <br />ASSIGNED TO:t V 1 <br />EMPLOYEE <br />DATE: <br />Date Service Completed (ii already completed): <br />SERVICE CODE: ci <br />PIE:7jC� <br />Fee Amount: �' (- C <br />Amount Paid <br />���►_ <br />Payment Date <br />Payment Type I_ -- <br />Invoice # <br />Check # <br />Recelved By: -� C <br />EHD 48.01.025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />