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SAN JOA( COUNTY ENVIRONMENTAL HEA 1611EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Guy �51 5"y <br /> OWNER/OPERATOR <br /> �� Sai2C CHECK If BILLING ADDRESS <br /> FACILITY NAME LCKJIFI�' <br /> SITECA�DCDRESS Co� [2P ,� <br /> 1 l 7 Street Number Direction Street Name C Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 0U0 1 [� �'" ►�--t"` `Street Number Street Name <br /> CITY (�`J1 TATE Zip� { <br /> PHONE#1 ,�,.\ '�c� EXT. APN# LAND USE APPLICATION#! <br /> PHONE#2 r� —� EXT BOS DISTRICT LOCATION CODE <br /> ("1L 1) �Jj`��.fy <br /> LLD <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � /, ^o 0 6 ^�E � CHECK If BILLING ADDRESS <br /> BUSINESS NAME �` lul j PHONE# EXT. <br /> HOME or MAILING ADDRESS <br /> C , 6-1 :(1' <br /> � A o-146- <br /> CITY �/ STATE oj__� <br /> ZIP �71 <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 <br /> or 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 and F E L laws. <br /> APPLICANT'S SIGNATU ` t DXEE: <br /> 2��PROPERTY/BUSINESSOWNER❑ PERATOR/MANAGER ❑ OTHERAUTHORIZEDAGEIfAPPLICANT i the BILLING PARTY,proof of authorization to sign is requir 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. T <br /> TYPE OF SERVICE REQUESTED: t,t W—.6—M-6F I T RECEIVED <br /> COMMENTS: ^1 1 Q 200 <br /> SAHNVJOAOUIN COUNTY <br /> EN,JIRONEN <br /> MTAL <br /> HF—:ALTH DEPARTMENT <br /> ACCEPTEDBY: 0L_C JrI IZ d�TEMPLOYEE#: ©3 Z� DATE: .- <br /> ASSIGNED TO: AA! 16—L` EMPLOYEE#: �r_"t � DATE: Ii;> 0 <br /> Date Service Completed (if already Completed): SERVICE CODE: 19 S P 1E: <br /> Fee Amount: - Amount Paid Z S,OO Payment Date <br /> Payment Type Invoice# Check# 19 2L to Received By: <br /> EHD 48-02-025 01,k IZt R <br /> SR FORM(Golden Rod) <br /> REVISED 11/17/2003 pei�_C5_(� <br /> ( du �Ogp <br />