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5AN JOAQUIN UNI'Y ENVIRONMEN'T'AL HEAL'` EPAR'l'MLN'l' <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 7`��L S o o <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE ADDRESS f <br /> 17 v J rYla'\ M C"n V e- cK:' b <br /> treet Number Direction Street Name Cil ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number C Street Name <br /> CITY ` \ STATE ZIP <br /> G <br /> C„ <br /> PHONE#1 EXT• APN N LAND USE APPLICATION# <br /> (20`1) <br /> PH NE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAME �1PHONE# EXT.'► C-C�L)r-� n� oG ybl - 633 <br /> HOME Or MAILING ADDRESS FAX# <br /> 1 009- ) y b 3 12 <br /> CITY``J Vp <br /> (:-V- <br /> V- ; STATE ZIP <br /> C G i'S1 o".!5- <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Slanda ds,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: `r DATE: <br /> PROPERTY/BUSINESS OWNER 11 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENTZ S-e co 1 r Q- <br /> lf APPLICANT is n t le BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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. <br /> TYPE OF SERVICE REQUESTED: U e. t ipAYMENT <br /> COMMENTS: <br /> SAN $7 2003 <br /> �,AN�pAOI 11N�C3V10E Y <br /> ep <br /> p�gE.IC H4 t�Lf N oFI <br /> Fn!VI{;ON��Etd1Pl HC!�.1NOl'r.,. ,'. <br /> APPROVED BY: EMPLOYEE#: qA DATE: _I-'1_�3 <br /> ASSIGNED TO: D EMPLOYEE#: '6 (J L J 7-0:5 <br /> 7n DATE: _� _J <br /> Date Service Completed (if already completed): SERVICE CODE:II P I E: <br /> Fee Amount: Amount Paid �� _ Payment Dale 1�1 7103 <br /> rPaymentType Invoice# Check# Received By: <br /> EHD 48-01.025 SERVICE RECJEST FORM <br /> REVISED 6.5-02 <br />