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SAN JOAQUIN l JNTY ENVIRONMENTAL HEALTH D_ .RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property / FACILITY ID# SERVICE R -.QUEST# <br /> [ NAV <br /> OWOR <br /> ER i PWo/p/1 <br /> CHECK If Bit UNG ADDRES <br /> tea/ 7�ljj ✓�� f�7y NIIII& 61'�; <br /> FACILITY NAME <br /> SITE ADDRESS S , ti l c ' <br /> Street Number Directionj (J Street N.ne it Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 5�1rll <br /> Street N ember (� Street Name JL <br /> CITY /,A /n1vt STATE fi ZIP <br /> PHONE#'l f r EXT. APN# LAND U/SEE AAP'PLIC,.'ION# <br /> ( 5) -7� STI Zl -dVd- �� - <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOF <br /> REQUESTOR <br /> �/J//R CHECK If�Ltr.ltc ADDRESS <br /> BUSINESS NAME /' C �! p E� ExT.` Z <br /> HOME or MAILING ADDRESS � FAX# <br /> 3 73Z /1 /,/&bla ,o-';I,,r/ Sit <br /> CITY e p STATE /" ZIP <br /> BILLING AC NOWLEDGEMENT: % the undersigned property or husiness owner, operator or a._`horized agent of same, <br /> acknowledge that all site and/,or project specific I NVIRONMI:NI*Al, HEALIII DEPARTMEN'l hourly charges as, ciated with this pro,jyCl <br /> or activity will be billed to me or my )usiness as identified on this form. <br /> also certify that I have prepared this application and that the work e performed will be done in accordance 'h all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards STA 1'I id PEDERAI, laws. <br /> X�61 �, -T <br /> APPLICANT'S SIGNATURE: D /`" / <br /> •� ATC�� <br /> PROPERTY/BUSINESS OwNE1111 O .RATOR/MANAGER 11OTImit AUTIIORIZED AGIENT ty <br /> , <br /> If it PPLICINT is not the 31LLING PART)'•proof of authorization to sign is required I T,•/e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of th, p•et rty located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envir, I,n nota /site assessment <br /> illtbrnlation to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL'II-I DEPARTMENT as soon as it is available rid -t 'he same time it is <br /> provided to nlc or my representative. <br /> TYPE OF SERVICE REQUESTED: L—� s' h El�/ECJ <br /> CO ENTS: <br /> c16163 -� SAY _ 52W3 y _ �� ��t„N-res <br /> SAN JOAQUIN COUNN <br /> �, fl3 O PUBLIC HEALTH SERVIn VSSION <br /> tN�•'Irnrd'"�^IT(`. HF;,LTH <br /> APPROVED BY: EMPLOYEE#: G DATE:, <br /> ASSIGNED TO: <br /> EMPLOYEE#: DATE: <br /> Date Serviceomple (if already Completed): SERVICE CODE: p)E; — 3p. <br /> Fee AmountILL Amount Paid Payment Datl <br /> Payment Type invoice# Check 0 Received By: <br /> EHD 48-01-025 SERVICE REQI =ST FORM <br /> REVISED 6-5-02 <br />