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SAN JOAQUIOUNTY ENVIRONMENTAL HEALT,,-WPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> p0 375 <br /> OWNER/OPERATOR J CHECK if BILLING ADDRESS <br /> FACILITY NAMExf-ALcab <br /> - n t /1 <br /> SITE ADDRESS e6cc6c) j-'- c, 1 ��OC 7Urn �Sa� <br /> Street Number Direction Street Name C ZIR Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> St,--t Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT' APN# LAND USE APPLICATION# <br /> PHONE#2 E%. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 1��\ I 1in.` CHECK If BILLING ADDRESS yam, <br /> BUSINESS NAME 1 I 1 (j vl J EM. Imo_ <br /> �ci ci�t� c rcr PZ"r# GI�-la cry l � a i <br /> HOME Or MAILING Lo( AY-DRESS ^ r�I Q �t.� ) <br /> CITY � 0 ' - Y-t ` STATE(T• ICS zip <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, and FERE laws. ^ If <br /> APPLICANT'S SIGNATURE: p C�4'Y-Y_ DATE: /�Z-44y_ �`, � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MA OTHER AUTHORIZEDAGENT S L:IYWb��t _ <br /> If APPLICANTisnotthe BlLLINGPAR7Y 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 at the same time it is <br /> provided to me or my representative. c�- <br /> TYPE OF SERVICE REQUESTED: JJ S ` <br /> COMMENTS: <br /> ACCEPTED BY: EMPLOYEE#: nDATE: <br /> ASSIGNED TO: EMPLOYEE#: <br /> --e <br /> Date Service Completed (if already completed): SERVICE CODE: !E: �2 <br /> Fee Amount: Amount Paid 19-7q. IJP Payment Date Y � V <br /> Payment Type L/ Invoice# Check# b'2(o Lf Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />