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SAN JOAQI"N COUNTY ENVIRONMENTAL HFAr '1 DFPAR'1 iMENT <br /> SERVICE REQUEST <br /> Type of siness or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME I /B 5 •(/•j�/C« /per// <br /> SITE DORES`S /f <br /> (�,/J8/t/r1e%t Number Directrect ion Street Na a Cit 2 otle / <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 APPLICATION# y <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> t ) <br /> 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ^i/ /15;�j"""/�GL. <br /> ' 7 CHECK U BILLING ADDRESS <br /> BUSINESS NAME ` /J PHONE# EXT. <br /> HOME or MAILING ADDRESS _ , 11 � rfU �ev FAX# <br /> /F✓7 J ( ) <br /> CITY kwkLI-117 <br /> ��Y// STATE zip tel' / <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 DGI'ARTMEN'T 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 applicatiot d that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, SA ' and F• ERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/RtKINESSOWNFR❑ OPEIW It/MANAGER ❑ OTHr.H.AUTHONizEn AGENT❑ <br /> /fel PPLICANT ix not the BILLING PARTY proof of authorization to sign is required Tide <br /> AUTHORIZA'riON 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 10 lite 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: C <br /> COMMENTS: <br /> SAN <br /> BJOAL�c�M:1" Peso <br /> YnJI" EISN40fii�rpPS1Al <br /> APPROVED BY: Y EMPLOYEE M DATE: ';7— <br /> ASSIGNED TO: Ally` EMPLOYEE#: Airll DATE: -12 1�1r-e"3 <br /> Date Service Completed (if already completed): SERVICE COD I E: �-j <br /> Fee Amount: 45 I Amount Paid Paym e 7 p 3 <br /> Payment Type Invoice# Check# ZJ -�I. Received By: -Z��_�. <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> RrVISFD 05-0? <br />