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--4' /S-2 . v o <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 91-i /tu I - lyn A RE 000Zg <br /> OWNER/OP�ATQR <br /> //_�`" HAL IL ft/5 H6 znr�D CHECK If BILLING ADDRESS Old <br /> FACILITY NAME 6/,U <br /> � C �- <br /> lJ � 4— <br /> SITEoff` �J <br /> ADDR SS �i/ � -9 14 <br /> Street Number Direction treeCityZi Code <br /> HOME or MAILING ADDRESS (If Different ffroy.Site Address) <br /> G� Street Number Street Name <br /> CITY I' STATEr QIP <br /> PHONE#1 (/ EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT —7LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME,t PH NE# EXT. <br /> N 14-1 w�0 2 2 '�-S - <br /> HOME or MAILING ADD SIS / FAX# / <br /> Ci (�VJ ROA <br /> CITY f STATE �q ZIP <br /> t <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 FEDERAL laws. <br /> APPLICANT'S SIGNATURE: �f u I �( DATE: 2 2- 0 2, <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 avail t the same time it is <br /> provided to me or my representative. � t�T' <br /> TYPE OF SERVICE REQUESTED: �® <br /> COMMENTS: Cine J g 20QU `0 <br /> U � ..'�1Qf ""1N JOA <br /> 'M0%'NROYV NMENTUN <br /> H�EPgRTM NT <br /> ACCEPTED BY: � M EMPLOYEE#: DATE: <br /> ASSIGNED TO: VrJ(v WjnnY �/�/t EMPLOYEE#: DATE: <br /> Date Service Completed (if,already <br /> ccco' leted): SERVICE CODE: PIE: 1(00Z <br /> Fee Amount: ��Z _ Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 I ' r I �)I I/ SR FORM(Golden Rod) <br /> REVISED 11/17/2003 1. O CCJJ Ww <br />