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SAN JOAQUI OUNTY ENVIRONMENTAL HEALTA�PARTMENT <br /> 5 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST'# <br /> Y" FftDOg11q S k 0 0. -70 5 7.2- <br /> (!!WNo IOPERATOR <br /> CHECK If BiLL]NTa ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS ! C 7a' J x-k Gr CO C? 1 S ^ C-K:DI15 <br /> Street Number Direction Street Name Cltv ZIP Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> _ Street Number Street Name <br /> CIN STATE ZIP <br /> PHONE#1 �. 74� <br /> LAND USE APPLICATION# <br /> {(201 ) �O) X351 40 <br /> PHONE#2 EXT.- SOS DISTRICT LOCATION CODE <br /> { 1 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR � o Zt l e r o J ! � CHECK if BILLING ADDRESS <br /> BUSINESS NAME O rC} O PHONE EXT` <br /> o� <br /> � - <br /> HOME or MAILING ADDRESS FAX# <br /> Del- <br /> CITY STATE G/ ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, opera-tor or authorizedagentof 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 he done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws. <br /> APPLT ZS SIGNATURE: S 17 <br /> DATE: <br /> PROPERTY/BUSINE-SrO E �j OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> f <br /> If CA of the BILLING RORTY,proof of authorization to sign is required Title <br /> AbUoTHORI2 TI[ONT RE LEA_E'.INF�]rl�MA�ON: When applicable, I,the owner or operator of the property located'at the <br /> hereby horize tt'i release Of�a y and all results, geotechnical data and/or environmental/Witeassessment <br /> information to the SAN JOAQUIN COUNTY ENV ONMENTA HEALTH DEPARTMENT as soon as it is available and at th t_is <br /> provided to me or my representative. N/!r <br /> TYPE OF SERVICE REQUESTED: bod <br /> COMMENTS: U 1q2 <br /> r swyle/y SAV V// <br /> rN ' <br /> Nmy <br /> ACCEPTEnBY: /� �/r j O EMPLOYEE#: DATE: 111117 <br /> ASSIGNED TO: EMPLOYEE#: DATE: q f <br /> Date Service Compl ed (if already completed): SERVICE CODE: O(� <br /> Fee Amount: 3 J Amount P ,�� Payment Date Q 1 <br /> Payment Type Invoice# Check# I Rebeived By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />