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SAN JOAQUIN,UN'I'Y ENVIRONMliN'I'AL HEAL'1'f�L R'I'MEN'I' <br />SERVICE REQUEST <br />Type of Business or Property <br />FACILITY ID # <br />CHECK It BILLING ADDRESS <br />SE <br />CE REQUEST # <br />PHONE# <br />o <br />Ext. <br />+&1-G 337 <br />HOME Or MAILING ADDRESS <br />r� S �4- l (•� jV Gi e r ci , 5/d e,v s e!y- , ac ►v .5 E N S o I'S <br />FAX # <br />(go`) <br />G / - 6 3 �- 7— <br />OWNER / OPERATOR <br />,,,, f c, <br />CHECK if BILLING ADDRESS <br />FACILITY NAME <br />ASSIGNED TO: <br />EMPLOYEE #: "73 t -i <br />DATE: <br />Date Service Completed (it already completed): <br />SERVICE CODE: ' <br />P l E: <br />Fee Amount: :X 7%' 0� <br />SITE ADDRESS�f <br />! <br />1 / <br />/ 1 F <br />S7 �, r <br />Tri y <br />Received By: <br />��3 9 <br />I <br />Sig / Street Number <br />DlrWecllon <br />Street Name <br />CR <br />ZI Code <br />HOME or MAILING ADDRESS (It Different from Site Address) <br />Street Number <br />-Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 <br />EXT. <br />APN # <br />LAND USE APPLICATION # <br />(zoq) 53 <br />38 4. <br />PHONE 02 <br />EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />Q Q <br />(2©9) CJJ <br />L ? AGM <br />CONTRACTOR / SERVICE RE, QUESTOR <br />REQUESTOR L—: h T E / / _ olj 7-v-aG—y_� S <br />C� O <br />S % ja-i77-;z,1_) o F (T �„rC '?OQ <br />CHECK It BILLING ADDRESS <br />BUSINESS NAME <br />CL r <br />PHONE# <br />o <br />Ext. <br />+&1-G 337 <br />HOME Or MAILING ADDRESS <br />r� S �4- l (•� jV Gi e r ci , 5/d e,v s e!y- , ac ►v .5 E N S o I'S <br />FAX # <br />(go`) <br />G / - 6 3 �- 7— <br />CITY <br />CITY S o G /� / c <br />STATE G,X <br />ZIP 4 <br />1311,1ING 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-IrAL-nI DEPARTMENT hourly charges associated with this projector <br />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, STATEand EDERA a s. <br />APPLICANT'S SIGNATURE': � DATE: <br />Pltol'Lit'ry / BUSINISSS 01VNIsH❑ OI'LRATOR/ MAN ❑ OTIirix ALrrnoRIZLD AGEN� S Q ! e M A19 <br />/f /1 PPLICANT is r 1/le l31LUNG PARTY j oof of authorization to sign is required Tirle <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the pqa <br />rty located at the <br />above site address, hereby authorize the release of any and all results, geotechnicalas <br />data and/or enviro/sessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available an�>Y Ic lfllc it is <br />provided to me or my representative. R41- <br />TYPE <br />4j- <br />TYPE OF SERVICE REQUESTED: <br />S % ja-i77-;z,1_) o F (T �„rC '?OQ <br />COMMENTS: L s � �� <br />lyz� <br />e G O N oC a.V y C G /Z-7 G 3 �� T� N Co k6 <br />CL r <br />C o A! % 1 A) o cLS/ M o o f/-�c Y`l /J1 <br />/ owot <br />C,y-7-i*f1ca%1o1V (CCR -'2(a30) <br />r� S �4- l (•� jV Gi e r ci , 5/d e,v s e!y- , ac ►v .5 E N S o I'S <br />APPROVED BY: lrl v t <br />EMPLOYEE #: C _Z <br />DATE: �` 2. & 1 0 L <br />ASSIGNED TO: <br />EMPLOYEE #: "73 t -i <br />DATE: <br />Date Service Completed (it already completed): <br />SERVICE CODE: ' <br />P l E: <br />Fee Amount: :X 7%' 0� <br />Amount Paid <br />Payment Dale ', B <br />Payment Type <br />invoice # <br />Check # $ <br />Received By: <br />EHD 48-01-025 <br />REVISED 6.5-02 <br />SERVICE REQUEST FORM <br />E <br />