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JHLV ,IVHljUl1V VVUIVIY 1G1V V11[V1V lV1L'lV 1HL 11L'HLIIY LL1'HK11vIL'IVl <br /> i I <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST# <br /> JZESID.EMi iA (_1A(a/Z/L . <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> CL til �CGG[T <br /> FACILITY NAME <br /> SITE ADDRESS y,JC/� �� � h1 r1 ry,-157 CA <br /> r <br /> t J c Street Number I Direction S asNam City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> S Ta,rh TE Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXL APN# LAND USE APPLICATION# <br /> ( ) 99 Z /J/" 1554ec19 c, <br /> PHONE#2 EXT- BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REOUESTOR }� <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> Gff EJ/V< �oNSC(L j'/Nj <br /> HOME or MAILING ADDRESS FAX If <br /> i'70- SOX 37f+ <br /> CITY UR LOUL STATE �� ZAP <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STA nd FEDER laws. <br /> APPLICANT'S SIGNATURE: � l2E DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ O RALmIORIzEDAGENT <br /> hfAPPucANT isnot the B/LLING 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:5U2F-A C <br /> COMMENTS: -O_J 4PAYMENT <br /> RECEIVED <br /> 097b SEP F, 5 202 <br /> SAN JOAQUIN COUNTY <br /> _C. (1V-P PUBLIC HEALTH SERVICES HEALTH 1L. <br /> APPROVED BY: EMPLOYEE#: I ' (/ � DATE: ©i9_ ar-6)jZ <br /> ASSIGNED TO: lam- i-7" . .,� EMPLOYEE#: e5_73 G.-6 DATE: 0'3- Z.SS—c` <br /> Date Service Completed (if already completed): SERVICE CODE: ,j'J P/E: 1�et <br /> Fee Amount: - Amount Paid "'fj �!�' Payment Date <br /> Payment Type Invoice# Check# < J Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />