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SAN JOAQUIN COUN'T'Y ENVIRONVIEN'I'AL HEIAI.TII DEPAR'I'MENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR <br /> 7-city <br /> jZipde <br /> FACILITY NAME Vv �"ti O��,-ti(I� � `1—e K <br /> SITE ADDRESS L rCJN 1 ��� W�1 Street Name <br /> HOME Or MAfLING ADDRESS (if Different from Site Address) ,^ <br /> l�l ' Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE O EXT. APN# LAND USE APPLICATION# <br /> (791 q4 ' ' 1 -7'� — l&G -- <br /> PHONE 42&O- Exr. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE R1:QUESTOR , <br /> REQUESTOR CHECK If BILLING ADDRES <br /> BUSINESS NAME PHONE# Exr. <br /> HOME.Or MAILING ADDRESS FAx <br /> LCITY STATE ZIP q ^ <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 ENVTRONMFN"IAL HEALTII DFYAR MI3NT 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 perfonned will be done in accordance with all SAN JOAQUtN <br /> COUNTY Ordinance Code s >ueRAL laws. <br /> APPLICA'NT'S S=`I :- DATE: . .0 ell. <br /> PROPERTY/BUSINKSS OWNER❑ OPERATOR/MANA(;ER ❑ OTHERAUTHORTZED AGrN"r❑ <br /> If t1PPLICANT is not the BILLING PAR7't'pr•oojof authorizatioai to sign is required Title <br /> AUT110RIZATION 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 /> infonnation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAT;I H DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me of my representative. <br /> TYPE OF SERVICE REQUESTED: Ccf)Al S Ct t .1 n 0-'L1 <br /> COMMENTS: N <br /> j a �1.��--r 1F C-o �/�E c-T7 d F,�t) f-4 s E 70 r SR` 7 / <br /> -T-D r/JJ.�L� I,C_��S i�2 � M Ql 7 �Df18 <br /> /\1 S�JOA4t1tN COLINTy <br /> ACCEPTED BY: 0 L r EMPLOYEE#: '2—/ DATE: G7 f <br /> ASSIGNED TO: � � MPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: ? PIE: 0 2 <br /> Fee Amount: BD Amount Paid �¢�" Payment Date Zp �� <br /> Payment Type Invoice# Check# Received By: <br /> � I <br /> EHD 48-02-025 SR FORM(Voiden Rod) <br /> REVISED 1111712003 <br />