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SAN JOA TN COUNTY ENVIRONMENTAL HEA 'H DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST <br /> 5rC <br /> OWNER I OPERATO <br /> / % ,'),•_ i-� CHECK It BILLING ADDRESS <br /> FACRRY NAME , / /„t �/•�•M <br /> SITE ADDR lit' <br /> A I1p� <br /> Street Number Direction (� f•f /�-( t(reet Name Ci 2i Cotle <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> - <br /> 00 <br /> "I�7 � , V rG" Street Number Street Name <br /> CITY STATE P <br /> 5 a/g <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> I ) H - Z1900 ora - iy - / - 3 6 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> / SERVICE REQUESTOR <br /> REQUESTOR <br /> ` CHECK if BILLING ADDRESS <br /> r <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY 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,S eDERAL laws. <br /> APPLICANT'S SIGNATURE: ?J <br /> DATES 7 <br /> PROPERTY/BUSINESSOWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZEDAC ENV (/ 10 <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 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. n / <br /> TYPE OF SERVICE REQUESTED: S S!-✓t���-�f� <br /> COMMENTS: Q <br /> 6�/dZ JRUEL/ <br /> 10C SAN JOCAC7f- <br /> PUBLICIl� <br /> @IVIRGIdM:E'":. <br /> APPROVED 8Y; EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M D ? DATE: <br /> - ` Date Service Comp ed if alread completed): SERVICE CODE: 3 s PIE: <br /> 0 <br /> I Fee Amount: Amount Paid - Payment Date <br /> 111 Payment Type U' Invoice# Check# Received By: <br /> I <br /> } <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 8-5-02 - <br />