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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> y lz C. L <br /> OWNER/OPERATOR <br /> JK CHECK if BILLING ADDRESS <br /> FACILITY NAME 64- <br /> C • / A1E�✓ <br /> )_ lr <br /> SITE ADDRESS S /Sv l l •(�Y �L LGVµj"J �ZZ1) <br /> Street Number Direction Street Name Cit 9Zi Code <br /> HO or M ING ADDRESS (if Qifferent from Site Address) o, <br /> S eet umber Street Name <br /> CITY �C� J STATE ZIP GI S Z ZD <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> cZ��l 3'� g — �tij l bv5 C) <br /> PHONE#2 ExT. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS 0 <br /> BUSINESS NAME i� PHONE# EXT. <br /> V <br /> HOME Or MAILING ADDRESS ` �'1 A-V <br /> ` , ,-e— (AX# ) T <br /> CITY - %„ �L N /�`f STATEo ZIP );-2 I J <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 ENvrRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or 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 an FEDERAL laws. <br /> z <br /> APPLICANT'S S�6 ATURE: <br /> ATE: <br /> PROPERTY/BUSINESS OWNER' OP OR/MANA R ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the 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 JOAQUrN 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: 0 L <br /> COMMENTS' /y MAR 2 6 _G <br /> SAN JOAQUIN COUNTY <br /> ENVIROMENTAL <br /> 1 , HEALTH DEPARTMENT <br /> ACCEPTED BY: tr av- t EMPLOYEE#: DATE: r <br /> ASSIGNED TO: l` �G0 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: Z P 1 E: Z 6 D <br /> Fee Amount: 2 5 O Amount Paid 2-E _ Payment Date <br /> Payment Type f Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />