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_ 0AIN . 0AYU11N 0,_UU1N'14 ll iN VIROiNiVIEN`lAL ttEAL'1'H IIEPAlt'1'MEN'1' <br /> 0 SERVICE REQUEST ti <br /> ,t <br /> Y " Type of Business or WroP FACILITY ;SERVICE REQUI~ST#; 6, <br /> F � its .'��'�-r`�F y��"✓^�a � i'-r` "s 1i � s �`'''� w� <br /> i'1'/ /o//i�i7/� {fix �x':.s. t.".t..,t 4 rfl;_ �•��lxsl} ,. r ,)s ' d',.. . I <br /> OWNER/OPERATOR <br /> CHECK If BI <br /> I r �iow !`�-� LING'AD E S <br /> �0b G6 kGl,51i -7W__(2 <br /> FACILITY NAME <br /> SITE A s5 <br /> �. ,,,,� <br /> � � , Say <br /> t Strert Number b)eotio t e Nam city XleCode a <br /> E HOME Or MAILING ADDRESS (If Dlfiarennttffrom Site Address) 5 <br /> �� ►•�v vv Street Number Street a e <br /> CITY 5 Are zl <br /> ax <br /> 3 PHONE#'I ErrAPN# LAND USE APPLICATION# <br /> y ) �f(q <br /> PHONE#2 ?• tat 3S DISTiICT 4i,birr >>' w LQCATIt7N COPE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> P RE QU)E$TOIt <br /> ;&;Ip. / CHECK If BILLING ADDRESS '+ <br /> BUSINESS NAME PHONE# r� �''f PXT• f i <br /> HOME or MAILING ADDRESS •�� FAx# D <br /> r { ) �0 � <br /> CITY STATE zip <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, y <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> i•. <br /> activity will be billed to me or my business as identified on this form <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQm , <br />`. COUNTY Ordinance Codes,Standards, TE d L laws. <br /> 1, APPLICANT'S SIGNA DATE: d e e D <br /> PROPERTY/BUSINESS OWNER❑ OPE /MANAGER , OTHER AUTHORIz£D AGENT❑ <br /> IfAPPLICANT' of the_BILLING PARTY proof of authorization to sign is required Titre <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL 14EALTH DEPARTMENT as soon as.it is available and at the same time it is <br /> provided to me or my representative. N'( <br /> TYPE OF SERVICE REQUESTED:,. So <br /> COMMENTS: trr44441 <br /> IC. �� 4 <br /> l <br /> x <br /> I'.. . AI�PfiOVEq BY f r4 a , EMPLOYE-#� <br /> ASSIGNED To �r <br /> EMPLQYtrt: ra. - DATE fr tr x <br /> }' nL <br /> Deal Service Colriploted (If ahead r- 5 2 PIE <br /> y compEeted) ERVICE COD@, , <br /> i <br /> � j <br /> Ftie Amount Amount Paid <br /> ayment Date , �s <br /> P , <br /> Ym YR c. ; Invaice, f <br /> Pa ent T e # Check# Received sy a <br /> f <br /> y' <br /> Es{D 48-01,025 l SERVICE REQU$�fT FORM <br /> REVISED 6;5-02 <br />