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JAiN JOAQU1N k-OUNIYL+tVVLRONIVIEN'1'ALHEAL'1'H UEVAHTMENJ' <br /> SERVICEREQTT'+^-, <br /> Type of Business or property FACILITY,I SERVICE REQUEST# <br /> ;SERVICE <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESSI <br /> FACILITY NAME <br /> �SHE ADDRESS (/ q n^ C �� C�,_,_ ) <br /> � � Kel u re"Ldt6,n- /• l S/tr/� 7 cily Zip code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> i G — �� S �� <br /> � Street Name <br /> CITY STATE ZIP <br /> /' A ZctA � �� . S"- <br /> PHONE#t Em APN# LAND USE APPLICATION# <br /> ( ) <br /> PHONE#Z Exr. 8OS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQ UESTOR � 6, t/ ) <br /> �/ I <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# El, <br /> _T $�3�-7 <br /> HOME Or MAILING AAA�D ID�RESOSFAX# <br /> L7� 7 <br /> J1 ( ) <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 iden[i n this form. <br /> I also certify that I have prepared this a plicat' an that w0 o be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, E and FED L ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR&ANAGER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tire <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; -ky i cJ <br /> COMMENTS: d%yy/Ga ^rnX G�`� <br /> f o3 2!6 PAYMEN' <br /> RECEI\/E[ 37.Al� <br /> AUG 14 2002 �d <br /> SAN JOAQUIN CO�UN <br /> APPROVED BY: EMPLOYEE#: /,eY NVIRONME TI1AiEJ ". '/: G - <br /> ASSIGNED TO: / A fyn _ EMPLOYEE#: 5,13 <br /> ,1 IC (-1 DATE: <br /> Date Service Completed (if already completed): SERVICECODEI S- PIE: n L <br /> Fee Amount: C.f Amount Paid $ j_I(45- (') Payment Date `fIt) <br /> Payment Type ,/ Invoice.# Check# -5�// o Received By: <br /> EHD 48-01-025 SERVICE REQUEST<FORM <br /> REVISED 6-5-02 /� <br />