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f <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST, <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER IOPERATOR <br /> CHECK If BILLING ADDRESS D <br /> FACILIrr NAME ��^�L S ✓1 t= �l "4 65-z %,I <br /> SITE ADDRESS W —TV-,4 <br /> � <br /> Street Number Direction Street Name C' ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> CITY Street Number Streel Name <br /> STATE zip <br /> t PHONE#1 Exr. APN# <br /> LAND USE PLIC TION# -7 <br /> { l 7 - 03- ! <br /> PHONE#2 Exr. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> f CHECK if BILLING ADDRESSJ:�- <br /> 1 <br /> BUSINESS NAME / CI! v7 4 y PHONE# <br /> 1 HOME or MAILING ADDRESS j i /)/r f / ( C� FAX# V l <br /> CITY s�YJ/�c� STATE ZIP Gr ~ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned pr erty or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENviRONtvt6TAL HEALTH DEPARTMENT hourly charges associated with this project <br /> 1 or activity will be billed to me or my business as identif on this form. <br /> I also certify that I have prepared this application an at the work to be performed will be done in accordance with all SAN JOAQUIN <br /> } COUNTY Ordinance Codes,Standards, STAT I RAI,laws. / <br /> APPLICANT'S SIGNATURE: DATE: </ <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is no the BILLING PARTY,proof of aulhoriZation 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 /> i information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the same time it is <br /> 1 provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S' rL �7ryclt� L_ <br /> t COMMENTS: L` <br /> RECE VED <br /> �2 3 2004 <br /> SAN JOAQUfN COUNTY <br /> ENVIRONMENTALACCEPTE6 BY: D L.1 VE( EMPLOYEE#; i�3�f TI)I] �T EN <br /> t ASSIGNED TO: { ESS EMPLOYEE#: l[{5! DATE: <br /> 6 �r 3 b <br /> Date Service Completed (if already completed): SERVICE CODE: p E: <br /> i S 2 x.02 <br /> FeeAmount: e7O Amount Paid �(p5,�tj Payment Date �t <br /> Payment Type f Invoice# Check# // Received By: <br /> ' EHD 48-02-025 <br /> REVISED 1 111 7/2003 SR FORM(Golden Rod) <br /> l <br /> 1 <br />