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SAN JOAQUIT,`OUNTY ENVIRONMENTAL 11EALT )EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property 'FACILITY ID# SERVICE REQUEST# <br /> S26 0 36�Sz) S- <br /> OWNER/OPERATOR <br /> 6 CHECK if BILLING ADDRESS <br /> FACILITY NAME1 111 ` <br /> SIT EADDRESS <br /> IAr-`3 <br /> �C�e'I-i IP•�n� ��I L��� �5 <br /> Z Streel Number Direction Street Name city Zia Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sheet Number Street Name <br /> CITY - STATE ZIP <br /> PHONE#1 Exr. APN# LAND USE AP I TroN# <br /> ( ) 3LC�) --7C?&Z- 063- Zs <br /> PHONE#2 Ex* BOS DISTRI T LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR \ t CHECK If BILLING ADDRESS <br /> �j l„ J Ur <br /> BUSINESS NAME PHONE# ' <br /> h; /It,., s ( F�' 3 W-6� <br /> HOMEOf MAILING ADDRESS/ O (� FAX# ) "3/1_O-7z J <br /> #” O -1 <br /> CITY pIO D� STATE 6� 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: z Z <br /> PROPERTY/BUSINESS OWNER❑ O ERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 119 <br /> IfAPPL7CANT is not the ! LfNGPAATY.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. �t^�-� �� <br /> TYPE OF SERVICE REQUESTED! i.t.P FA-r—,E �t C <br /> t Srt.L i�r vTc E Cd Arr PAYA <br /> COMMENTS: ECCI VCE) <br /> 7�>�S JUN 2 <br /> 2 2004 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONHEALTH DEP ENTAL <br /> ACCEPTED BY: O LL V l(P EMPLOYEE#: (J-3Z 1jDato <br /> ASSIGNED TO: 4, I n/ EMPLOYEE#: �3(p 6 <br /> Date Service Completed (if already completed): SERVICE CODE: 3P 1 E: �_G'3 <br /> Fee Amount: /�' ,c7L� Amount Paid PaymentPayment Type Invoice# Check# ived By. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/172003 - - ' <br />