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JHIV ,JVA�U1lV �U1V1Y L.1V V11CVIVlVI L'lV1HL IIL'HL1t�L'1'HK11V1L'lVl <br /> SERVICE REQUEST <br /> Ty §f Business or rope y FACILITY ID# SERVICE REQUEST# <br /> �DO3� S <br /> OWN R/OPERATOR 0a U <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME L. <br /> SIT AD,4FiE SC 330 r <br /> r <br /> Street Number Direction tree t Name ZI Cotle <br /> HOME or MAID en <br /> ADDR�E/SS (If Dif t m froSlt Address) <br /> n <br /> `/ N (q7 Street Number Street Name <br /> CITY )PTE ZIP OICiX, rQ 7 <br /> PHONE#1 EXT. APN If LAND USE APPLICATION# <br /> (V ) - a );90-70Ca <br /> PH E#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUES R M / <br /> t! CHECK If BILLING ADDRESS <br /> BUSINESS NAME t PRpNLE,# EXT. <br /> J <br /> HOME Or MAILING A RES$^T`- f FAYIf <br /> CITY l-/�`V✓"1 �-.n/J t S lyf ZIP 9t5a-?OA,it <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 applicr tion and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA' E land FEDERAL laws. <br /> APPLICANT'S SIGNATURE: I I DATE: I� U 0 //�N,, <br /> If <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTIIER AUTHORIZED AGENT <br /> APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title till//// <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 HEAL'rU DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: P'aivl� r <br /> COMMENTS: PAYMENT <br /> RECI=-)VC0D <br /> NOV - 12002 <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENWL HEALTH DIVISION <br /> APPROVED BY: EMPLOYEE#: V4 DATE: _I-U <br /> ASSIGNED TO: EMPLOYEE#: J, O DATE: If_ <br /> Date Service Completed (if already Completed): SERVICECODE: I /^ PIE: - <br /> Fee Amount: N t"—7 00 Amount Paida Payment Date I I � I r-' <br /> Payment Type Invoice# Check# L' Received By: <br /> EHD 48-01-025 — \ SERVICE REQUEST FORM <br /> REVISED 6-5-02 \ <br /> a <br />