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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID S SERVICE REQUEST 0 <br /> Cwt,--2l <br /> O R/OP RA OR CHECK H BILUNG ADDRESS❑ <br /> FAaLRY NAME <br /> I1 <br /> S- <br /> r Di beet Namd C <br /> HIMILINrl ADDRESS (If Different from Site Address) I ZgCo 7 (� � <br /> Street N��umberJ <br /> CITY CJ C Ca OVA STATE � ZIP <br /> 1. E*- APN A LAND USE APPLICATION 0 l� <br /> PHONE#2 Exr. BOS DISTRICT ./ LocATom CODE <br /> ( ) Dc s <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> RE 77, <br /> I CHECK if BILLING ADD ' <br /> BUSINESS NAME <br /> a PHM# 3-7 <br /> HOME or MAILING ADDRES4 FAX# <br /> ,'i ofir,\n r- 19v-p— t ) <br /> CrrYCJ&/\ STATE 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 <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,Standard , ATE aad FE RAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNEI✓IB.J OPERATOR/MAN G ❑ OTHER AUTHORIZED AGENT❑ <br /> 1,fAPPLiCANT is not the BILLING PARTY,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 environmentaUsite mens <br /> inforTnation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the <br /> provided to me or my representative. NP <br /> TYPE OF SERVICE REQUESTED: Tor' I I O <br /> COMMENTS: <br /> %J_J <br /> Dov 1� 1',1 +0 Chant oo NMF�V 8 <br /> yu �e1c1 C0. <br /> ACCEPTED BY: EMPLOYEE#: DATE: I <br /> ASSIGNED TO: EMPLOYEE : DATE: C <br /> Date Service Completed ( already comp) ed): SERVICE CODE: t P1 ( O <br /> Fee Amount: 16 Amount Pai Payment Date g-7 <br /> Payment Type �— Invoice 9 Ch ck IM S� G Recei By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> t 6 <br /> `F 1$ -, <br />