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SAN JOAQUINCOUNTY ENV1KULN1Y114:1N1AL, 11 r--111L --- <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> - Type of Business or Property o o (— I � 353 <br /> �chool vl "� vl <br /> OWNER/ OPERATORI t(N� CHECK if BILLING ADDRESS❑ <br /> `i rac{ iJ VJi ed (1 11 / I <br /> FA YA E �kVU <br /> SITEADDRESS <br /> 3 Street Number Direction GG,^, <br /> ` 1a 51 Street Name f Ci Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CI STTATFj zip <br /> 1uC� <br /> if ft <br /> PHONE#1 FxT' APN# LAND USE APPLICATION# <br /> ( moi) 23703 -70'1 <br /> PHONE#2 ET. BOS DISTRICT LOCATION CODE <br /> v <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR , _R f (SNI,t (r Jey C_e3 ticCHECK If BILLING ADDRESS <br /> p I <br /> BUSINESS NAME { l t J PHONE# 6(0Z—Z <br /> ME <br /> HOOr AILING Arn S { FAX If <br /> CIE zIPd '7 <br /> 57 / <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,STATE andFEaw. A ( <br /> APPLICANT'S SIGNA'T'URE: /C- �/w DATE: <br /> I/I I Z c n 7 <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER OTHER AUTHORIZED AGENT NJ A°6�ir <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 <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 a�the-same time it is <br /> provided to me or my representative. PP I 1�D <br /> TYPE OF SERVICE REQUESTED: U n) Q uwL <br /> COMMENTS: <br /> SAN jOVIRaNME Ti Kf <br /> VIEW V4 <br /> DEPPA <br /> ACCEPTEDBY: � = V V'v �� EMPLOYEEM 231 -7 DATE. I (b O-� <br /> ASSIGNED TO: �.� <br /> EMPLOYEE D'7 S3 DATE: ( (Q U <br /> Date Service Completed (it already completed): SERVICE CODE: V C' PIE: 2 b <br /> Fee Amoaid Payment Date <br /> S � <br /> Payment Type Invoice# Check# 5 j _ ,i Received By: <br /> EHD 48-02-025 ° (9A FORM(Golden Rod) <br /> REVISED 1111712003 t( / y(L-/ <br />