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SAN JOAQUIN l,.,UNTY ENVIRONMENTAL HEALTH DE. ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Ga cog ►2� <br /> OWNER/OPERATOR (t q 1 q, t V A ^ ie— CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME (�aa/� C -1 -2— <br /> SITE <br /> SITE ADDRESS `L� <br /> Street Number i ecc— tree l� Name Cit i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 1 6 l Street Number Street Name <br /> CITY STAT VA <br /> Zip !� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (4+�NEl) q 5-- Cl <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR 36 /i^ S�/ 1 t <br /> �/�I f Vt Y CHECK If BILLING ADDRESS <br /> Cl <br /> BUSINESS NAME n `� { ` 1?3 PHONE �� �Lj 0 I ExT' <br /> HOME or MAILING ADDRESS /` FAX# -I <br /> CITY STATE ZIP (IC <br /> BILLING ACKNOWLEDGEMENT: 1, 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 /> COUNTY Ordinance Codes,Standards,STATE and F DERAL laws. <br /> APPLICANT'S SIGNATURE: 4,AJW <br /> ` DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATE R/MA AGER OTHER AUTHORIZED AGENT 11If APPLICANT is not the BILLING PARTY,proof o authorization to sign is required Title <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 the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: �Cpit <br /> COMMENTS: <br /> SqN I I U ZQj <br /> ��q <br /> '1447-, p pPONT�t <br /> ACCEPTED BY: fv &AGAA V � EMPLOYEE#: DATE: 1 O <br /> ASSIGNED TO: ` , \;)a C�A EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type�Q� �9 f Invoice# Check# Received By: � <br /> EHD 48-02-025 `f� p��1 t�'� SR FORM(Golden Rod) <br /> REVISED 11/17/2003 yyy"'ttt P <br />