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SAN JOAQUIN C `JNTV ENVIRONMENTAL HEALTH r ''ARTMENT <br /> %-� SERVICE REQUEST u <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �1ESiDEn/ l L L u S/Z0035 g9/ <br /> OWNER/ OPERATOR <br /> O14 CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSr C /�Q✓JL�pe <br /> C� 5 b! Slreel Number Dir/eclion Street Name OW Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APYLICATIOK# <br /> ( , .r7- a?o - b WIA 3 —S I <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( , <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR DO <br /> N ehirEJ .N/F " CHECK If BILLING ADDRESS <br /> BUSINESS NAME Cn�� �S/'G / / / PHONE a EM <br /> HOME Or MAILING ADDRESS Vr /V FA%# <br /> 0 . <br /> CITY lj/-06g <br /> STATE ZIP S-Fj/l/ <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,StandardISE and FEDI 1. rs. ? <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MrANA.ER ❑ OTI .R Al1T1IORIZP.D AGENT <br /> If APPLICANT is not the BILLINGPART 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 sante time it is <br /> provided to me or my rept alive. <br /> HAY IM EN I <br /> TYPE OF SERVICE REOUESTED. Col z- szflTAB L/ r ST D >r-✓ P <br /> COMMENTS: <br /> NOV 3 2003 <br /> 3 Q� SAN JOAQUIN COUNTY <br /> ENVI <br /> HEALTH DEPARTMENT <br /> APPROVED BY: /In ,Ie'�r Os EMPLOYEE#: 716-7 DATE: 0 J-3 63 <br /> Q 2 <br /> ASSIGNED TO: -.r�t� {�/) EMPLOYEE#: 9 3-7" f DATE: 00 <br /> 3 0 <br /> 3 <br /> Date Service Completed (if already completed): SERVICE CODE: 6-2-Z- P I E: <br /> Fee Amount: da 0� Amount Paid /9 — Payment Date <br /> Payment Type +,,' Invoice# Check# ) e eive-d By: /7 <br /> EHD 48-01-025 SERVICE REQUEST <br /> REVISED 6-5-02 <br />