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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVeft REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> E z/ <br /> OWNER/OPERATOR //e� <br /> Com/ I ING ADDRESS <br /> FAC <br /> fMW <br /> SIT EADDRESS 600 S 7W/-rr o6?4. 2-//YAr4 9�a3 <br /> Street Number Direction Street Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) /beS IN' W fj-j-7-WMe$,,OVe <br /> Street Number Street Name <br /> CITY „nSTATE i// ZIP <br /> PHONE#1 Ez. APN# LAND USE APPLICATION# 7 <br /> I.W S3-7-Z rb /r07-O�o a3 <br /> PHONE#2 Ex. BOS DISTRICT LOCATION CODE <br /> f ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR - <br /> N CHECK If BILLING ADDREssa <br /> BUSINESS NAME L ` ,ur PHONE# E' . <br /> sP /7 .� 33%- 66i <br /> HOME or MAILING ADDRESS ,n O FAX# <br /> (.iii <br /> CIN ,(� STATE ZIP <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,STATE and FED AL law Z <br /> APPLICANT'S SIGNATURE: rlU DATE: / o'3O <br /> PROPERTY/BUSINESS OWNER 11 OPERATO / IANAG OiNER AUTHORIZED ACEN <br /> If APP[/CANT is not the BILLING PAR TK 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 availahl���ame time it is <br /> provided to me or my representative. l ENEC) <br /> TYPE OF SERVICE REQUESTED: SO/IS l/UT KG Dic / <br /> COMMENTS: � �. <br /> AN JOAOUIIA GOUNN <br /> H 'A U AHTMENT <br /> R U 2 f Z��U�o 3 a �mrn �� <br /> NO � � <br /> 26 <br /> APPROVED BY: /�w v I ./J A EMPLOYEE#: D3�/ DATE: <br /> ASSIGNEDTO: tl CSctO L- <br /> EMPLOYEE#: (/ptf - DATE: ` 3C} Qk <br /> Date Service Completed (if already completed): SERVICE CODE: c1Z2 P 1 E: ;?��,Q <br /> Fee Amount: ., 0 u -2= Amount,Paid Payment Dto <br /> Payment Type Invoice# Check# 5 i i Received By: N (L- <br /> END 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />