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SAN JOAQ- COUNTY ENVIRONMENTAL HEAL'I._ a)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> C)C) 2 01 DG S(- �3 5O> <br /> W ER/OPERATOR l^, <br /> ' f 1. CHECK If BILLING ADDRESS <br /> FACILITY NAME Q <br /> SITE ADDRESS l 2� S J Lµ 5 33 <br /> Street Number Direction ["` Street Name u` City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# / LAND USE APPLICATION# <br /> ( ) «lv iloo � <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR c <br /> '`� (� ����� _ 1 , _ ��I h CHECK If BILLING ADDRES <br /> BUSINESS NAME\(\J��� �c "'CCC ����(� (1S 1 PHONE# l .—��4( EXT. <br /> OM or MAILING A4DRE�SS C` s FAx# ) <br /> �� c T <br /> `� �S STATE (' ZZ 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,S dards,STATE and FEDERAL laws. <br /> APPLICANT'S S ATURE: DATA <br /> PROPERTY/BUSINESS OWNER OPERATOR/M GER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPL IC T is not the BILI proof of authorization to sign is required Title <br /> AUTHORIZATION TO k=ASE 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. w, <br /> TYPE OF SERVICE REQUESTED: -ooG 6� Lt. PAYMENT <br /> COMMENTS: RECEIVEn <br /> NOV 19 <br /> SAN JOAQUIN COUNTY <br /> ENVIRoMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: r S L EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: \ 3 P 1 E: <br /> Fee Amount: 3 > Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />