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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST# <br /> Type of Business or Property S�C)C-�3 r�5 (p 1 <br /> 'L O <br /> OWNER/OPERATORoaf SSF CHECK If BILLING ADDRESS❑ <br /> f�' <br /> FAclirn NAME i9 r 1A) <br /> Si�cl� .J 'tet <br /> SITE ADDRE 5 % n code <br /> "'%;ILame �, J <br /> Street Number Different <br /> ntfro <br /> HOME Or NIAILING ADDRESS (If Different from Site Address) Street Name <br /> Street Number <br /> STATE zip / <br /> CITY / 7�" Exr APN# LAND USE APPLICATION# <br /> PNONE#1 <br /> (2, /�V2) e / / BOS DISTRICT LOCATION CODE <br /> PNONE# / �/ <br /> ( t09) D <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> WO <br /> REQUESTOR I ;/� Jc ©/Z , G <br /> BUSINESS NAME �fn .�`�£ �t/ �N�• <br /> FAx <br /> HOME Or MAILIN ADDESS <br /> (STATE CITY LQl� 1 <br /> BILLING ACI4NOWLEDG-MENT: 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 JOAQUIN <br /> STATE and a <br /> COUNTY Ordinance Codes,Standards, O <br /> DATE: <br /> APPLICANT'S SIGNATURE: <br /> PROPERT\/BUSINESSOWNER❑ PERAT R/MANAGER OTH AUTHORIZED AGEN/LI� Tate <br /> IfAPPLICANT is not the BILLI G pARTY proof of authorization to sign is required T <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�te assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is availabi.,an th G I time it is <br /> provided to me or my representatives �j <br /> TYPE OF SERVICE REQUESTED: S I /L L J <br /> COMMENTS: <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> / I <br /> 7 <br /> E#: DATE: r <br /> EMPLOYEtttlll <br /> APPROVED BY: DATE: <br /> EMPLOYEE#: � t(� <br /> ASSIGNED TO: V PIE: t y <br /> SERO 3 <br /> Date Service Completed (if already completed): Payment Date /J <br /> Fee Amount: Amount Paid a,•'] �; D <br /> ived By: <br /> Payment Type Invoice# <br /> Check# Z�'[J Rece <br /> SERVICE REQUEST FORM <br /> EHD 48-01-025 <br /> REVISED 6-5-02 <br />