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SAN 'JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY,/I�# SERVICE REQUEST# <br /> T <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> FAC LITY �/ <br /> SITE ADDRESS / V <br /> Q Street Number Direction Street Name Cit Zi Cade <br /> 1-19FElor M#41NGG ADDRESS f if Different from Site Address) <br /> V A/'p / Street Number Street Name <br /> STATE zip <br /> PRONE#1 EXT. APN# LAND USE APPLICATION# <br /> (�r�) &3 -677 r 2- - '_7/0- C)tn <br /> PHONE#2 EXT. BOS DISTRICT LOCATION OPE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> Rcnl ST <br /> CHECK if BILLING ADDRESS <br /> B IN N E PH NE# EXT. <br /> �/ <br /> HOME or(MAI A gs FAX# <br /> 15 i1 &4 — # <br /> CITY STATE eA ZIP 9a 7k-n <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that ail 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 w k to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S AT and FEDERAL lay s. p <br /> APPLICANT'S SIGNATURE: DATE: 04 d 6 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOCtI�[ANAGER OTHER Au-rHORIzFD AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is require Tule <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 andlor 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 represenAle. C I L F( <br /> TYPE OF SERVICE REQUESTED: RECEIVE) <br /> COMMENTS: `l JUN 'd <br /> JUIN 2 zoos <br /> SAN JOAQUIN r- TY <br /> SAN JOAQUIN COUNTY ENVIROI\,,L <br /> ENVIRONMENTAL HEALTH 0FP: r <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ,' f li^ t �_, EMPLOYEE#: C132--1DATE: <br /> ASSIGNED TO: �� U.fL^ F- L- c.( E EMPLOYEE#: 7 DATE: 6, R- <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: -7300 <br /> Fee Amount: C—1 Amount Paid 'Payment Date , 12- 0 <br /> Payment Type �� Invoice# Check# 5 Received By: C� <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/1712003 <br />