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-r-ilI ILIA,AJUDW-kt,In 10 WAKI 1V11+,'NT <br /> SERVICE REQUEST <br /> _Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ' acs Css`� <br /> ©WNER/ OPERATOR ---� <br /> CNECKifBILLING ADDRESSE] <br /> FACILITY DAME <br /> SITE ADDRESS 1 _�, f �� �1 '„ `�'� <br /> Street Number Direction ` 1 eet Name1 "o}`' �'j� cit ZI Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number <br /> CITI' rvaqw- <br /> STATE zip <br /> PHONE#IEXT. APN# LAND USEAPPLICATIOIV# <br /> t <br /> PHONE#2 E)cr• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUEST( <br /> CNECK if BILLING ADDRESS <br /> BUSINESS NAME 1 �. <br /> HOME or MAILING ADDRESS � , r <br /> CITY 4 STATE ZIP <br /> 9S 69= <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> 1 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 FEDERAL Ia s. <br /> APPLICANT'S SIGNATURE: r DATE: <br /> PROPERTY I BUSINESS OWNER❑ OPERATOR/MANAGER ❑ HER AuTiioxtizED AGENTYen <br /> If,4PPLICANT is not theBH.LINGP,4RTY proof of authorization to sign is requiredr Till e <br /> AUTHORI A'nGN TO RELEASE INFORMATTON: 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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> PAYMFNT <br /> TYPE OF SERVICE REQUESTED: �x RECEIVED <br /> COMMENTS: 2009 <br /> SAN JOAQUIN COUNTY <br /> — ---- ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED B - EMPLOYEE#: DATE: <br /> lo <br /> z � <br /> ASSIGNED <br /> -- TO: . r <br /> - <br /> [)ATE:EMPLOYEE : <br /> 76 <br /> hate <br /> Service Completed (ifalma SERVICE CODE: P <br /> Fee Amount: Amount Paid >� O O Payment Date <br /> to <br /> Payment Type ✓ Invoice# Check# b Received Sy: <br /> EHI7 48-02-025 s; it <br /> Golden�tod}` T <br /> REVISED 11/17/2003 <br />