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SAN JOAQI . COUNTY ENVIRONMENTAL HEAL*EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> oC2 0 <br /> OWNER/OPERATOR ' CHECK if BILLING ADDRESS❑ <br /> / FACILITY NAME <br /> 1-1:5A /I:5A 5 LG2��-` <br /> SITE ADDRESS t -53'�„i, 4-61; dJ� z 3 <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP /j <br /> PHONE#'I EXT. APN# LAND USE APPLICATION# <br /> C&I ) 72 7 5.7 S 1 o >t 10 u l <br /> PHONE#2 EXT• BOS DISTRICT LOCATIgN CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> i �O CHECK If BILLING ADDRESS <br /> USINESS NAME 1 / PHONE# EXT. <br /> HOME or MAILING ADDRESS FA'X# <br /> -) C - ( ) <br /> CITY I STATE /? A zip 0 S-2 <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 app ' ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,S F L laws. <br /> APPLICANT' IGNATURE. - % DAT <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ PIUSI 9L—py / <br /> If APPLICANT 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 environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available mat the same time it is <br /> provided to me or my representative. I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: L G� L�l/JV�+ Sc � SAN�Oq 2013 <br /> ll ENVt QUtty C <br /> hEA�rty��qF� ��1Y <br /> I- <br /> 4160 <br /> ACCEPTED BY: �,t EMPLOYEE#: DATE: 1 7n ZJ <br /> ASSIGNED TO: I\r t EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ( PIE: C� <br /> Fee Amount: 7 j '�, Amount Paid D D Payment Date (Z / <br /> Payment Type Invoice# Check# Receiv d By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />