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I SAN JOAQUIN' OUNTY ENVPIZONMENTAL HEAL'fl -1EPARTMEN'f Q,� <br /> SERVICE REQUEST ' [ `— <br /> Type of BusinProperty FACILITY ID# SERVICE REQUEST# <br /> a1� �A00o1554 512t7o411°4g <br /> WNER OPERATOR ,,.., �T�nn ,�l ( , <br /> L �I vt J' h CHECK If BILLING RESS <br /> FACILITY NAME <br /> SITE ADgREg7�S`t � yT ,e �� ,�(a <br /> Street Number Direction n <br /> " `Slreel am ` aa77 Cit ZI IDde <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Slreel Number Street Name <br /> CITY STATE zip <br /> PHONE#1 EXT• APN# LAND USE APPLICATION# <br /> PHONE#2 EXT- DOS DISTRICT LOCATION CODE <br /> l ) <br /> CONTRACTO / SERVICE REQUESTOR <br /> REQUESTOR <br /> t � CHECK If BILLING ADDRESS <br /> BUSINESS IN E PHONE# Ear. <br /> HOME AILINGA RESS FAX# <br /> Y� <br /> CITY <br /> STATE,-�r` 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 HGALTN 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 Cor/es,Standards, STATE and FEDERAL laws t q <br /> APPLICANT'S SIGNATURE:_C_ ✓ � , c"' ` -1/ DATE: <br /> PROPERTY/BUSINESSOWNF.ROPERATOR/MANAGER ❑ Oritru AUTIIORI7.F.D AGENT <br /> If APPLICANT is not the BILLINGPART 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 HGALTIi DEPARTMENT as soon as it is available an ��(-{ale same time it is <br /> provided to me or my representative. Pp,�(M�t" ' <br /> lrn <br /> TYPE OF SERVICE REQUESTED: US—r- a2-,F•IY2-U F t"r <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> APPROVED BY: U L-(V E.( l,�A EMPLOYEE#: 3zf DATE: i CA <br /> s- <br /> ASSIGNED TO: -�Ce SO� EMPLOYEE#: (r3- DATE: 2—'If olo-C <br /> Date Service Completed (if already completed): SERVICE Coor: ( p PIE: <br /> Fee Amount: W , L Amount Paid a,7 Payment Date <br /> I C)Payment Type Invoice# Check# s { a�71 Received Sy: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />