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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> �. SERVICE REQUEST .� <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � 20o3�33k, <br /> OWNER/OPERATOR� <br /> CHECK if BILLING ADDRESS <br /> 1 \ <br /> FACILITY NAME <br /> SITE ADDRESS T ��,^� ' O _P /�. n Li_1 ,� <br /> IZ- Street Number 0irection Street Name C{,� V `fC w Zi Code <br /> HOME Or MAILING ADDRESS Q Different from Site Address <br /> Street Number Street Name <br /> CITY TE ZIP <br /> PHONE#t _ EXT" APN# LAND USE APPLICATION# <br /> cwt �Ip�� I�'S8 O 8 <br /> PHONE#2 EXT" BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> _ <br /> BUSINESS NAME PHONE# ))TT _ EXT" <br /> HOME or MAILING ADDRESS ,�5 FAX# <br /> ( ) <br /> CITY QS-2 <br /> "7 c STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 1, 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 erfo d will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE and FEDERAL laws <br /> APPLICANT'S SIGNATURE: ATE: y— 19-03 <br /> PROPERTY/BUSINESS OWNER PERATOR/MANAG OTHER AUTH RIZED AGENT❑ <br /> If APPLICANT is not the BILLING 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 environmentaVsite assessment <br /> inforTmation 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: <br /> COMMENTS: R F_C E I V E D <br /> SEP 19 2003 <br /> t 1r� q Y SAN JOAQUIN COtJR.1TY <br /> RONfICHLA'IFNTAI HESER� lrN <br /> APPROVED BY: ti k, <br /> EMPLOYEE#: 6 yl3 DATE: <br /> ASSIGNEDTO: EMPLOYEEM ®/ DATE: <br /> Date Service Complete (if alrea ycompleted): SERVICE CODE: PIE: (.Qo <br /> Fee Amount: l �� Amount Paid Payment Date ) a <br /> Payment Type Invoice# Check# f Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 8-5-02 <br />