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I Page1 of 1 <br /> 2004-03-23 98:34:23(GMT) 12092313124 From: Neil O'Hara <br /> 'am raft. <br /> SAN JOAQt)IN COUN fY ENVIRONMENTAL HEALTH i)k:r'ArIt'V <br /> SERVICE REQUEST <br /> NNU.,; <br /> Type of Business or PropertyCM <br /> F,gGILITY ID# SERVICE REQtJI^S f ff <br /> OWNER/OPE TOR <br /> ESBLUNADDRSCNECK it -S❑ <br /> FACILITY NAME f <br /> SITEADDRESS <br /> 1///j0 Street Number p;rectiork <br /> 7� <br /> Street Name CI Zin Code <br /> HOME or WAILING ADDRESS (If Different from Site Address) , <br /> Street <br /> CITY Number 5 eat ame <br /> STATE ZIP <br /> PHONE#1T• AP # LAND USE APPLICATION# I <br /> o --030- <br /> PHONE#2 ExT. BO$DiSrRICT <br /> ( ) t•tiCATION CpAE <br /> REQUE5T4R CONTRACTOR/ SERVICE REQUESTOR <br /> �Av/a CHECK if UrLLINGADDRESS <br /> � <br /> BUSINESS EX <br /> NM Q r PONE# T !!!!!! <br /> �SoG 6 ;O <br /> HOME olp AELINGgRE55 FAX# <br /> L <br /> T : , <br /> STATE ZIP /] <br /> BILLING ACKNOWLEDGEMENT: f, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or prgiect specific PANVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this praiecL <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 `;ANJoAQt;IN <br /> COtTNTY Ordinance Codex,.$74jrdrrr-r/-%:,STATE and FEDER.At laws <br /> .AP-PLICANT'S SIGNATURE: ' <br /> - - -- ---__— DATE, <br /> PROPERTY/BUSINESS ChAl'ERE3 OPrRATOR/M NAGEIt © OTITER.AUT}TORt7,EU AGENr <br /> 1/tlrrl,Ic_.r:iri.r 17o1 r1le&ILLIN.PARTY,,proofnj'authorizurion t0 sign i.srequired Trr1e <br /> AUTHORIZATION TO.RET,FASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all .results,.gcotechnical data and/or cnv.irtmtrlental/site assessment <br /> inforptation to the SAN JOAQUIN COUNTY f-7tiV1R0141 ivTAL HEALTH DEPARTMCNT as soonas it is available and at the saute tine it is <br /> provided to nie or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS, 4 <br /> necEvED <br /> r- ravteuu <br /> 77 77� <br /> APPl30VEt?BY:. -- Utt'1 GO <br /> ACS lSN <br /> /`,$SIGNED 70 EMRL.oYEE# flATt , <br /> Dat@.SerVICe Completed (ri already Gnrnplated} SERVICE COF]E <br /> Fee Amount <br /> Alnotlnt�> <br /> at <br /> F'ayent Type ZiA <br /> lnvorce# Check # <br /> EHD 4M1-025 <br /> r <br /> REVISED 6-5-02 SERVICE REQUEST FORM ' <br />