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SAN JOa.QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Ty Linerty FACILITY ID# SERVICE REQUEST# <br /> -ia S f0043o <br /> OWNE .. <br /> CHECK7:1 <br /> JFACILITY NAME <br /> SITE ADDRESS <br /> � treet Number <br /> HOME or MAILING ADDRESS (if Different from Site ess) <br /> ---�S5 S' L - �{a7 . <br /> Street Name <br /> CITY STATE ZIP <br /> 9 LFUCo Z <br /> PHONE#t 7-7 E��] APN# <br /> LAND USE APPLICATION# <br /> (WO) 3Ub ( I — I�r —a3 9— ila�s <br /> PHONE#2 BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> REQUESTOR <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> / <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME <br /> PHONE# EaT• <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE 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 projector i <br /> activity will be billed to me or my business as identified on this form CwLx'J ) <br /> I also certify that I have preparedthis app can n and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards TATE d FED (/ <br /> APPLICANT'S SIGNATURE DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTEIORIZED AGENT 11 <br /> IfAPPLIGSINT 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 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: REGEIV ED <br /> COMMENTS. Y/zv/oc t/�s�� srll oto 0 1 4 2005 <br /> .��t-�J>rrvrc�rm ���I�✓ � JUL � <br /> /1I.0' E3cer7ioSAN dOAOUIN COUNTY <br /> 63EAY/A)) ENVO DEP RiMENT <br /> NFJ�LT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE M 9 DATE. _ S <br /> Date Service Completed (if already completed): SERVICE CODE: _3i-,31PI E: <br /> Fee Amount: Amount Paid Payment Date -71) LH DS <br /> Payment Type ✓'' Invoice# Check# D Received By: <br /> 141�6— <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />