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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> b"PA 4x >< -15467-& SP-0p OS l <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS❑ <br /> GFT A6&46 t t1TS GG G /683 l tcN,ffZr I �rE �s� CA' �77 7n <br /> FACILITY NAME r t MM &�po g <br /> SITE ADDRESS <br /> Azz Street Number Direction GW tee N Cil Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �.IK.QYV� 5'/� <br /> Street Number LCNN Street a e <br /> CITY /9VW& $TgTE ZIP D <br /> PHONE#1 rV ExT• APN# TLANAYYPPLICATION# <br /> ( f 7NE?) �S?- 220$ ZCo�SSO O!o <br /> PHONE#2 EXT• BOS DISTRICT L/ LOCATION CODE <br /> CAJOk MAW <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS C❑ <br /> BUSINESS NAME PHONE# EXT. <br /> �DSTcIDZo } / GTS X57- 2208 <br /> HOME Or MAILING ADDRESS FAX# <br /> 3 AA Ilk' '1510 c 1 <br /> CITY 17979 V)1` STATE zip <br /> 56 <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 I[EALTH 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 /> COUNTY Ordinance Codes,Srandar,l �Ar and FE- .RAI. laws. <br /> APPLICANT'S SIGNATUR • DATE:�/ WA0/`) <br /> PROPERTY I BUSINESS OWNER❑ OPERATO _r1 1NAGER ❑ OTHER AUTHORIZED AGENT — <br /> If APPLICANT is not the BILLING PARTY•proof of authorization to sign is required Ti fl e <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable,1,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 e t <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: /(Iii/F74/WI� WN�//rtwc—J/uN. •"'�1Ti��jT'�f�%7�Y'v�vi !�����cF�/ � `. ,; <br /> Ft644A� o' )W"+1r �,,M� v lAL <br /> ACCEPTED BY: EMPLOYEE#: DATE: / ZZ, r L <br /> ASSIGNED TO: EMPLOYEE#: DATE: `�V <br /> Date Service Completed (if already completed SERVICE CODE: ,r'• _ PIE: 0 <br /> Fee Amount: Amount Pal 7SC� o0 Payment Date 1 <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />