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SAN JOAQUIN f ouNTY ENviRONMENTAL HEALTIRnEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 - 3v / E2, <br /> OWNER I OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FAcam NAME <br /> �i <br /> SITE ADDRESS IC <br /> Street Number Direction Street Name city ZID Code <br /> HOME or MAILING ADDRESS (If Different front Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE LICATION# <br /> ( I 13� 3� zv oa _ �� <br /> PHONE#2 Exr. SOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRE <br /> Cl nFc� <br /> BUSINESS NAME _ _ • �, PHONE# Exr' <br /> Ar v1�S�r. �✓nl T S`bCl I'L"` IV Ih 209 `ni — 1Y7 45 <br /> HOME Or MAILING ADDRESSFAX# <br /> 5 <br /> 53c I ( ) <br /> CITY - { ` if C 1' STATE CA 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: y;j��3yl �� ���„AL1Ati— DATE: J(-)tge- Ht X(02 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENTP pt'7 -) -�?[fy;rr"-- <br /> IfAPPLICANTisnot the BILLING PAR TPproofofauthorilationtosign isrequired 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 dataind/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon\las it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: S <br /> COMMENTS:7 p YM <br /> 1 <br /> I'S�"t RECEIVED <br /> P' r � 1 UN <br /> J IA;yA 172002 <br /> SAN JOAQUIN COUNTY I <br /> •.% I':►�pQ Ute=��2r'T li`r��7 � pUBLI ENEALTHSERNCES <br /> HEALT DNMS <br /> APPROVED BY: EMPLOYEE M DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Comple (if already c leted): SERVICE CODE: j P 1 E: (F�� <br /> Fee Amount: 7 Amount Paid Payment Date <br /> Payment Type Invoice# Check# j� ( Received By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />