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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST a7 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> 1 0""11 <br /> CHECK If BILLING ADDRESS <br /> J /� 10 s "" ✓r G2 I` <br /> FACILITY NAME <br /> SITE ADDRESS / � Gtr' / � l/UL LCt t:fJ 3 /tP <br /> Street Number Direction Street Name Ci Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY ) TE ZIP <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (�! ) I'70 - 3 <br /> PHONE#2 ExT• BOS DISTRICTLOCATION CODE <br /> ( ) ., �3 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR n!J � <br /> !��Y�N� CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex-r. <br /> HOME or MAILING ADDRESS s /� FAX# <br /> CITY 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,Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ��j [r L01 a-110— DATE: fJ % �j <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 13-�— Dianne P I`II trar,r <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Licensirrf,l"�PoordiriaRc <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: C,O/u _ ouc L i d-LAj.--tc-e— EN <br /> COMMENTS: <br /> JUN 18 200 <br /> SAN JOAQUIN COU <br /> ENVIRp1V1yfE <br /> HE4LTH DEAL <br /> PAR MEN <br /> ACCEPTED BY: t J� !1 EMPLOYEE#: 03-2--i DATE: l_ 1�-- D <br /> ASSIGNED TO: O � EMPLOYEE#: t 104 DATE: (S� t EVA) <br /> Date Service Completed (if already completed): SERVICE CODE: j P 1 E: <br /> Fee Amount: GS. Amount Paid GJ _ Payment Date <br /> Payment Type Invoice# Check# 2 ` Received By: �( <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />