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JAN JOAIIUIN I.OUNPY ENVIRONMENTAL VIRONMENTAL HEALTH DEPARTMENT <br /> L. SERVICE REQUEST .._» <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> >A . \ 1T �( L� <br /> FACILITY NAME /T LCHECK if BILLING ADDRE55� <br /> +J I <br /> SITE ADDRESS <br /> 22 SSb Street Number <br /> Direction Name Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 5338 Vi�fi�c /-!mac y]i,•�-c <br /> Street Number Street Name <br /> CITY D Yah $TATE _� ZIP <br /> �� 152-D <br /> PHONE#1 Ex . APN# LAND USE APPLICATION# <br /> PHONE#2 En. BOS DISTRICT LOCATION CO E, <br /> ( ) !11 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME sr �/JV� PHONE <br /> HOME or MmuNG DRESS ( FAX# <br /> OS>CJSO ( ) 67 Z <br /> CITY / _ STATE CJj ZIP G <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,Stand rds, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: f DATE: <br /> - /0 r ° <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ O' HER AUTHORIZED AGENT pI <br /> IfAPPLICAAT is he BILLING PAR TP 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 representative. <br /> TYPE OF SERVICE REQUESTED: get Zf j4 CF- C-0 nJ? D 1-0 <br /> COMMENTS: /�/� <br /> �f RECEIVED <br /> jot <br /> Ir AUG 1-0 2004 <br /> SAN JOAQUIN COUNTY <br /> (00/rlrt/ ENVIRONMENTAL <br /> ACCEPTED BY: EMPLOYEE#: f,3.Z DATE I C <br /> ASSIGNED TO: S C ..-rr-�1 EMPLOYEE#: V�9 DATE: � /O 6 <br /> Date Service Completed (if already completed): SERVICE CODE: i P E: zG 03 <br /> Fee Amount: /S(c.0� Amount Paid { / 8'(0 , Payment Date (0/0 y <br /> Payment Type Invoice# Check# /Y 7 Received By: <br /> EHD SR FORM(Golden Rod) <br /> REVISED SE011/111/17/2003 // Iy�r�7A�leYi�et.7✓[�� A - <br /> C <br />