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SAN JOAQUIN"�,I LINTY ENVIRONMENTAL HEALTF�— EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> A Kfeat-ry LIgr-S/DENT1,4L <br /> OWNER I OPERATOR <br /> OA/ A10e -'r-/ Ca-Alf t4E4V lvo;�E CHECK if BILLING ADDRESSEI <br /> FACILITY NAME <br /> SITE ADDRESS V/ 80 kllgAA/ �RENC�f Chir° 9SZ 3/ <br /> 3 Street Number Direction Stree!Mame <br /> Ci Zi Code <br /> HOME or MAILING ADDRESS {if Different from Site Address) <br /> Street Number Street Name <br /> CITY <br /> STATE ZIP <br /> PHONE#1T APN# LAND RISE AP LICATIO <br />} PHONE#2 Exr. 13- 7-6 a <br /> k ! BOS DISTRICT LOCATION CODE <br /> i <br /> REQUESTOR <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> Dw ' <br /> ,ry/V �/7 CHECK if BILLING ADDRESS <br /> BUSINESS NAMEG �1Nr� � ^`r�L!/AI� PNONE# >xr• <br /> VJ <br /> i HOME or MAILING ADDRESS. 0 FAX# <br /> 7 c <br /> CITY G��-zsyS <br /> �—u <br /> LO <br /> CK STATE 7IP9 -78 <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this applicatio and that the rk to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STAT FEDERA a s <br /> APPLICANT'S SIGNATURE: DATE: 3 Z r <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN GER ❑ OTHE AUTHORIZED AGENT <br /> If AAPLlC.lNT is not the a:L G P tRTy proof of authori on!o 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 /> inforniation 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: uBS'lflZrA 9F60Arl jjIAIA7-/per/ h <br /> C / <br /> COMMENTS: i e _ <br /> MAR 2 4 2004 <br /> SAN.10AC7U1N COUNTY <br /> ENVIRONMENTAL <br /> y EALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: � DATE: <br /> Date Service Completed (falready completed): SERVICE CODE: <br /> '�� � PIE: O <br /> Fee Amotant: , Amount Paid Payment Data <br /> Payment Type-,•. Invoice# Check# J2 �1 i Received By: <br /> oG <br /> i <br /> EHD 48-02-025 _ <br /> REVISED 19/17/2003 SR FORM(Golden Rod) <br />