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SAN 4OAQU`'�OUN'I'Y ENVIRONMENTAL HEAL' DEPARTMENT 1 <br /> SERVICE REQUEST l <br /> j Type of Business or Property € FACILITY ID# SERVICE REQUEST# € <br /> C 0 e Thr Lk Smo-3 <br /> rOWNER I OPERATOR t <br /> 12) <br /> CHECK if BILLING ADORES <br /> ❑ <br /> c:.sse f+ <br /> FACILITY NAME I <br /> 1 SITE ADDRESS <br /> Street Number Direction Street Name Cit 2i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Stree[Number <br /> Sheet Name <br /> CITY STATE zip <br /> C � e�c-n e n� :� �� <br /> PRONE illAWN# LAN USE APPLICATION# <br /> �•4-C _C 7- <br /> PHONE#2I ExY. BOS DISTRICT LocION COD <br /> O <br /> s <br /> j CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR 4 CHECK if BILLING ADDRESS <br /> BUSINESS NAMEc� � Ih� O e PHONE# EXT, <br /> 9 Q_ r o <br /> HOME or MAILING ADDRESS FAX# <br /> Q (a07) a.7- q D <br /> CITY C k 5�J STATE CT}_ zip Q5 ap� <br /> I E 'r` <br /> BILLING ACICNOWLEDGkMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ]ENVIRONMENTAL HGALTji DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me ormy 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.IOAQuIN <br /> COUNTY Ordinance Codes,StAndards, S-FA-I'E and FIiDERAL laws. <br /> APPLICANT'S �SIGNATURIDATE <br /> E: <br /> llitoi-Eiii'Y/BUSINESS OWNER❑ OPERATOR/MANACEtt ❑ OTnEIt AUTHORIZED AGENT❑ <br /> If AI NL iCaNT i rtor rhe Brr_r-IN_ _G P�f�proof of authorization to sign is reqrrired Tilfe <br /> AUTHORIZATION TO RELEASF INFORMATION- When applicable, 1, 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 /> infOr111ati0h to the SAN JOAQUIN COUNTY ENVIRONMEN-rAL HEAL?-ii DEPARTMEN"r as soon as it is available and at the same time it is <br /> I provided to me or my representative. <br /> I <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: RECEWED <br /> x OCT 2 7 243 <br /> SAN.IOAQUiN COUNTY <br /> 6 PUBLIC HEALTH 5E€'V OES <br /> j ENOOMMENTAL HEALTH UNISION <br /> APPROVED BY: � EMPLOYEE#: SC, DATE: a�2 7-03 <br /> ASSIGNED TO: r EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 7 5 P/E: a <br /> Fee Amount: 0 O M Amount Paid Payment Date t O <br /> Payment Type ✓ EM Invoice# Check# �S 6 Received By• <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br /> E� <br />