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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Gv- <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME C�-��Ss/"D�l���' �•�'lc� Cc��%rY��i�` G'�jGl`G�-r <br /> SITE ADDRESS <br /> /5`'5 Street Number Direction / Street Name [ CZip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1�5-7 C <br /> Street Number t Name <br /> CITY f i�G ^J/+STATE ZIP ��53 7 <br /> PHONE#'I EXT. APN# CLAND USE APPLICATION# <br /> (9-z5 ) 95 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 1 <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> BUSINESS NAME v y/ ! [ PHONE# _ EM' <br /> HOME Or MAILING ADDY FAX# <br /> CITY 27��'C< STATE / ZIP % �j�✓�` <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 the work to be performed will be done in accordance with all SAN JOAQurN <br /> COUNTY Ordinance Codes,Standards,� aI FEDERAL la s. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER)( OPE TOR/MANAGER OTHER AUTHORIZED AGENT❑ <br /> LfAPPLICANT 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 time it iS <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> CT,S,oO�M��C�N <br /> ACCEPTED BY: 1 , Y r o e/-C/► l J EMPLOYEE#: DATE: Q <br /> ASSIGNED TO: S 1 t .I it r, EMPLOYEE#: DATE: <br /> Date Service Completed (if already co leted): SERVICE CODE: D;n 1 P/E- <br /> Fee Amount: t lc�l �,� Amount Pai /5-,,2 0 D Payment Date Z� <br /> Payment Type Invoice# Check# 9G $ Receiv By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11A7/2003 <br /> IS I S <br />