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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHJDEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY M# SERVICE REQUEST# <br /> 52 rn:3 r Z3 <br /> OWNER 1 OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> "°55 woods nd 4cAmgszz0 <br /> Street Number Din-i.— Street ane ' ZI Cove <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> �•D J(J� SlmtNumbsr Street Name <br /> CITY ^ STATE 21P 9 5z-z--c <br /> PHONE#i Em APN# LAND USE APPLICATION# <br /> 5- c yo -0/- <br /> PHDNE#2 Ex . SOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Enr' <br /> 33¢-G 523 <br /> HOME or MAILING ADDRESS �� fj (Ax# ) <br /> 21 1p <br /> CITY / d�" STATE CA ZIP 957— ,55-0 <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 SIGNATUREA" DATE: O - <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> /fAPPLICANT is not the BiLLINGPART7 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 environmentallsite 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:. <br /> COMMENTS: ql/ / � /p�ri��a RECEIVED gyp <br /> (a4 u. f� r� I1G3 020021414D 1jo <br /> V , — AN JOAQUIN COUNTY <br /> P� 31".1 PUBLIC HEALTH EROC€5 <br /> ENV4RONMENIPL HEALH Dl3�t, � <br /> APPROVED BY: EMPLOYEE#: L' C DATE: G ? <br /> ASSIGNED TO: EMPLOYEE#: C/- C DATE: <br /> Date Service Compl d (if air Completed): SERVICE CODE: 7 Z PIE: (� / <br /> Fee Amount: ( Amount Paid - Payment Date <br /> Payment Type Invoice# Check# Recelved By: Z <br /> EHD 413-01-025 SERVICE REQUEST FORM <br />