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�ruv v VrLl1Ul1� L.V U1V I Y l'IV V1KUiVIV1LIN IAL 11LAL1'H]L)EPAK•i'1YIE:N'1' <br /> W SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# <br /> H' S 5�� I C b y , 1 SERVICE REQUEST# <br /> OWNER/OPERATOR �p ✓ <br /> f Q-O CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME P� O a,), I O <br /> SITE ADDRESS 1 1 Oo b <br /> Streel Number Direction S ree R2rrfe city ZIv Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> zStreet Number Street Name <br /> CinSTATE ZIP <br /> I�a V1 C Jq C) CQ �O l/c� C;-+ 9 5-7 `if Z <br /> PHONE#I EXT APN# LAND USE APPLICATION# <br /> o 9 v <br /> PHONIER EXT• BOS DISTRICT ' ' LOCATION CODE""+ <br /> t <br /> CONTRACTOR/ SERVICE RE' QUESTOR <br /> REQUESTOR O IZ 1 t+d Ll <br /> �- f2 CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME Tf� PHONE# EXT. <br /> _ft1 f G <br /> HOME Or MAILING ADDRESS FAX# <br /> 32 3 LLAVL.ctu6 ( ) Ib ! 1 <br /> CITY Y.9,0-Y� C k O C6 C _! O\J C.'- STATE C /4 ZIP <fl -7 (q <br /> 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 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,Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: c7/ 1; DATE: Z /D <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT P— fQ n1 pD—11a n C e 1tiL <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 and at the same time it is <br /> provided to me or my representative. <br /> +- TYPE OF SERVICE REQUESTED: Fr--w nt( T- 1`O V'Z 12 E-P LO Ce{M��1'� r �}(� l] =TQC']-6 <br /> COMMENTS: <br /> _ ,pAYMEN <br /> RECEF <br /> :,AN JOA0.oIN COU <br /> APPROVED BY: EMPLOYEE#: x, DATE: <br /> ASSIGNED TO: �� EMPLOYEE#: •_.: DATE: <br /> 3 r <br /> Dato Service Completed (if already completed): SERVICE CODE; <br /> —7 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type L� Invoice# Check# Received By <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6;5-02 <br /> r <br />