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SAN JOAQUIN(--.JNTY ENVIRONMENTAL HEALTH Dt-—RTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR �^n G C�� n <br /> v 1 + ! CHECK If BILLING ADDRESS <br /> FACILITY NAME /A f 5 O`'n/1 w • t,\ A ✓vvx/� <br /> SITE ADDRESS f�/'Lj, 10 •` IS A ✓�n � <br /> Street Nulm`bler Direction t `T��/ I Ci i Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 1 2 �� t <br /> r' �1! ' Street Number Street Name 7 <br /> CITY �" k C(A VWy) ' STATE C ZIP q C C 3 I <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# J <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR /n� <br /> I�VI s-c ,/t/► /A `/+1 l f n, ��� CHECK if BILLING ADDRESS <br /> BUSINESS NAME' ` , 1 L`►r lv` V r V PHONF# EXT. <br /> Seg Ca n <br /> HOME or MAILING ADDRESS J�� f -� FAX# <br /> Q �q�� !t'7 ( ) /� <br /> CITY "t"„n� r A V„A( STATE CA ZIP `'.1 c2 <br /> 2 1 <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 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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: aosojgl cl- yir1a n u u/a DATE: 7— eV Z�KO <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> JAN <br /> yFAk-r,HHDNIN <br /> MLI'Al <br /> ACCEPTED BY: , 'r l Vwli1 J EMPLOYEE#: DATE: MENr" <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if alread completed): SERVICE CODE: 1 ,o PIE: 1 <br /> Fee Amount: I C:5 2— Amount Paid Payment Date -2-02ZL) <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />