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SAN JOAQUIN MUNTY ENVIRONMENTAL HEALTH D- .,RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> F A- (�D�I �� <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> e L'O nu <br /> FACILITY NAME i <br /> r +0 <br /> SITE ADDRESS u` {6 S -A U� <br /> S <br /> Street Number Direction I r tr t NUO A city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> C cLo :i�� ' Street Number Street Name <br /> CITY F7r-Pn G /W/�^ ! STATECA <br /> ZIP <br /> PHONE#'l EXT. APN# LAND USE APPLICATION# <br /> (2,0q 1 2— 6 - 2-7 <br /> PHONE#2 EXT. r <br /> ISTRICT LOCATION CODE <br /> r( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Sr L b Cw rhe r o CHECK If BILLING ADDRESS O <br /> BUSINESS NAME PHONE# EXT. <br /> -� VJ2-)5 -2-75 <br /> HOME or MAI NG ADDRESS FAX# <br /> D C r CLa ( l <br /> CITY I^ STATE If A ZIP <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 identi led on this form. <br /> 1 also certify that I have prepared this application an that the work to be performed will be done in accordance with all SAN JOAQuIN <br /> COUNTY Ordinance Codes,Standards,STATE nd DERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERA OR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> If APPLICANT 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 ENVIRONMEN"rAL HEALTH DEPARTMENT as soon as it is available and at the Sam��tir�,it is <br /> provided to me or my representative. PAYMENT <br /> 1NT <br /> TYPE OF SERVICE REQUESTED: RECEIVEL <br /> COMMENTS: NOV 0 5 2E <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already Completed): SERVICE CODE: 0(p P/E: �v 3 <br /> Fee Amount: I C)Z Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />