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SAN JOAQUIN 0)UNTY ENVIIZONMEN'rAL HEALTII I)EPAW MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID If SERVICE REQUEST If <br /> OWNER/OPERATOR <br /> 11'l�n CHECK if BILLING AODRESSE] <br /> FACILITY NAME ✓ <br /> S �/ <br /> L DTES !q�reet umber DI IIon Mo a�Ireel Name ©- I�� Zip 7 .5�d O <br /> HOM1E Or MAILING IOADDRESS (If Ditferegt from Site Address) <br /> Street Number <br /> Street Name <br /> CITY STATE ZIP ��`S Z3 a <br /> PHONE#t EST• APN# LAND USE APPLICATION# <br /> — 444-, 1 le9 51120—02185--)/&q f'?—o3-/4'�JCms <br /> PHDNE#Z EXT. BOS DISSRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> RE UESTOR <br /> ` A Y CHECK II BILLING ADDRE55� <br /> BUJE55 NAME,'` f _ ^ PHONE# EXT <br /> t!rZA62 .. <br /> 5 W�h+ e) 34-G��f <br /> HpMYr�Or MAILING ADDRESS FAX <br /> �' CEJ ( ) <br /> CITY / STATE ZIP '^5—'7 <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,Sl tdards,STATE and FE-/TDDEE!-R�ALL WS. <br /> APPLICANT'S SIGNATURE: ' / DATE: <br /> PROPERTY/BUsiNESs OWNER OPERATOR/MANAGER ❑ TITER AUTHORIZED AGENT <br /> If APPLICANT is o/t 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. <br /> TYPE OF SERVICE REQUESTED: .�-g-� $ <br /> COMMENTS: `/�/�� <br /> PAYMENT <br /> RECEIVED <br /> /Z�ot7/7eJtc� <br /> DEC 5 2003 <br /> 1 0 <br /> SAN JOAQUIN COUNTY <br /> FNVIRQNMENTAI <br /> APPROVED BY: EMPLOYEE#: (!)� EA-T'H/ ENf T NT <br /> ASSIGNEDTO: � J EMPLOYEE#: CC/(f� DATE: <br /> Date Service Completed (if already Completed): SERVICECODE: 3 PIE: 2'013 <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice# Check If Received By: <br /> EHO 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />