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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rloazo N <br /> OWNER/OPERATOR <br /> C, CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS �� �2i� S ��I�� �� t ����.l^ O��'�✓J <br /> Street Number Direction Street Name L Ci l_T-� Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / 1 � �� TC-7-0 N `�L <br /> � I <br /> Street Number Street Name <br /> CITY STCEb-of ZIP <br /> PHONE#1 EXT- APN# LAND USE APPLICATION# <br /> (S'1C)) � `76 -6160 <br /> PHONE#2 EXT. BOS DISTRICT --] LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> a C) c CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> C 2 550 7� — <br /> HOME or MAILING ADDRESS FAX# <br /> 79 I n R Fr)N ( ) <br /> CITY lJ—j��L1:1's- <br /> BILLING <br /> )- STA TF� ZIP ( n <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 /> 1 also certify that 1 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 DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /0 f a J ,}9 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> /f APPLICANT is not the BILLING PART} 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 enviro site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available fW fne it is <br /> provided to me or my representative. J <br /> TYPE OF SERVICE REQUESTED: C � Oc.. <br /> COMMENTS: SAN,/O <br /> C In(/u/LC �SI�P MEACT t OAIACo TAL <br /> LINT y <br /> h'0EPART <br /> ACCEPTED BY: /Y/1 b 0 EMPLOYEE#: DATE: 42c <br /> �\ASSIGNED TO: vk( EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 0(0 P 1 E: lop <br /> Fee Amount: 2 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 /> fo"0534145 <br />