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Z <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> k <br /> L R L <br /> OWNER/OPERATOR <br /> n 4 v Al �r CHECK if BILLING ADDRESS <br /> FACILITY NAME A1V VA C► <br /> SITE ADDRESS -F- <br /> STA r PLE D E !� <br /> -147260 Street Number D-r;etion Street Name Ci Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> P. © Street Number Street Name <br /> CITY STATE Zip <br /> 3 oc v CA �z0 <br /> PHONE#1 Ex,, # LAND USE APPLICA # <br /> - 3¢v -e;,4- <br /> PHONE#z Exr. s BOS DISTRICT LOCATION CODE <br /> { ) <br /> CONTRACTOR :ERVICE REQUESTOR <br /> ' REQUESTORDoa 11!5C CHECK if BILLING ADDRESS <br /> Er <br /> BUSINESS NAME w`{f L7 PHONE# CoGgr Exr. <br /> HOME or MAILING ADDRESS / PAX# / <br /> 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 <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 he work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FEn ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/ ANAGER ❑ THER AUTHORIZED AGENT i <br /> If APPLICANT is not the BILLING PARTY proof of aut oriZation 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 environmentaVsite 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. <br /> TYPE OF SERVICE REQUESTED: SaAFAZG1�7 A tJDAr"IN <br /> COMMENTS: fj� O <br /> �y RECEtVED <br /> a 6.T NOV 2 3 2004 <br /> SAN JOAGIUIN COUNTY <br /> NVIRONMENTAL <br /> ACCEPTED BY: �L r� ! w EMPLOYEE#: <br /> ASSIGNED TO: � N Pr EMPLOYEE#: �. b DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: 3/S P/E: �� p� <br /> Fee Amount:� .OC7 Amount Paid (�' D� Payment Cate Z3 a t f <br /> Payment Type Invoice# Chef ck# j b� Re f 2. By: <br /> EHD 48-02-025 <br /> REVISED 11/17/2003 SR FORM(Golden Rod) <br />