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-tee <br /> 4I` c)Its �-2e— <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER OPERATOR / CHECK If BILLING ADDRESS❑ <br /> FACILRY NAME <br /> SITE ADDRrE�SS <br /> 3 5 C �Ilt BVeet Number Direction Street Name CI Zip Code <br /> H0MEt7fMAILIN9ADDRESS (If Different from S�riltfeAddress) <br /> Iw�f,1 L �S rK.\ Street Number Street Name <br /> CITY ZIP_/ <br /> l 414\— STATE i- I\ <br /> l--r-t �C, 7 Z <br /> PHONE#1 APN# LAND USE APPLICATION# <br /> I ) <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> t ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK If BILLING ADDRESS <br /> BUSINESS NAMEt PHONE# EXT. <br /> let - 1 \ <�<i C 0 -)-ALIS <br /> HoMeor MAILING ADDRESS FAx# <br /> Pzs- r_ /(2c•' 1 4 c"7-Ct-21 <br /> CITY },•, Oz ` STATE C A ZIP 'q'5-2fj <br /> _ <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 hourl} charges associated with this project <br /> or 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,STATE and FEDERgI-laws. <br /> APPLICANT'S SIGNATURE: / « DATE: <br /> PROPERTY/BUSINESSOWNER❑ 0, "1 OTHERALTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required r Title <br /> AUTHORIZATION TO RELEASE 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 andor environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART)IENT 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: REG 'A'%IC <br /> rr <br /> JUN 1 3 2005 <br /> SAN JCFG-RN COUNTY <br /> ENVI RO;d.I Et ITAL <br /> ACCEPTED BY: EMPLOYEE#: WIJ H TE: G <br /> ASSIGNED TO: EMPLOYEE#: $ 6 DATE: <br /> Date Service Completed (if already Completed): SERVICE J:OpE: PIE: <br /> G <br /> Fee Amount: Amount Paid�� — yment Date 3 �� <br /> Payment Type Invoice# Check#/ �-J as Received B � <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />