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SAN JOAQ .J COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> al %u— CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> I L,L c ¢.sSk. <br /> SITE ADDRESS S.C1C•Z•G1-� <br /> C) Street Number Direction Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EExT• APN# LAND USE APPLICATION# <br /> ( ) (p 0 2 U U 2(o « 0� <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) CMZ <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> PW---A- <br /> HOME Or MAILING ADDRESS FAX# <br /> (=I) ? r. Z <br /> CITY�M I STATE<JPA zip 9 <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 E ONMENTAL ALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business dentified orm. <br /> I also certify that I have prepared thi on th the o to be performed will be done in accordance wit all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s; a <br /> APPLICANT'S SIGNATU DATE: LZ Lei 3 <br /> PROPERTY/BUSINESS OWNER❑ T ANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is no 1LL1NG 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: C� Pal �� Rv�^ <br /> COMMENTS: <br /> HEp►,T <br /> ACCEPTED BY: EMPLOYEE#: '716 ?U DATE: <br /> ASSIGNED TO: s� � EMPLOYEE#: (' (� DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: `,Z P I E: 1 1, p <br /> Fee Amount: 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 />