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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> Z I '�)2 <br /> OWNER i OPERATOR <br /> (66' a'9'" CHECK if BILLING ADD SSYo1_ <br /> FACILITY NAME (5�CCL 4 - "Om � 4�� <br /> SITE ADDRESS C2-J_ <br /> (Street Number I Direction I q treet ame (t� <br /> Cit ZI Codell <br /> HOME Or MAI1115 <br /> ADDRESS (If Different from Site Address) <br /> OQStreet Number Street Name <br /> CITY STA ZIP <br /> — -Zmdju�az� ( -4rT- 5 <br /> PH NE#t U Exr. APN# �Q—r' LAND USE APPLICATION# <br /> 2PHON (30 e�afi 629 Ido 0 -12- <br /> PHONE <br /> E#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ` <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILINGAMPRESS FAX# <br /> CITY STATE 84- <br /> ZIP <br /> BILLING ACKNOWLEDGEM T: 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 /> 1 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 FEDE ws. <br /> APPLICANT'S SIGNATURE: DATE: Ay �( /�9 <br /> PROPERTY/BUSINESS OWNEtc���{\ OPERATOR/MAN R ❑ OTHER AUTHORIZED AGENT 11If APPLICANT is not the BILLING PARTY,proof of 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 environmentaUsiltee�a_ssessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the _it is <br /> provided to me or my representative. �"" 1T <br /> TYPE OF SERVICE REQUESTED: Ne J `LO� .� <br /> COMMENTS: l 0�'( ac' \ C ``_ S�J ?5 20 <br /> kf1"AN yIRO/VM Al-r <br /> DEPARTM t <br /> ACCEPTED BY: CGL J-� LS EMPLOYEE#: DATE: I C •Z <br /> ASSIGNED TO: �l EMPLOYEE#: DATE: ' •2 I <br /> Date Service Completed (if already completed): SERVICE CODE: PIE:, te' O <br /> Fee Amount: ,f--u Amount Pa ��00 Payment Date 1 <br /> Payment Type Invoice# Check# �S ��S Receive By: <br /> EHD 48-02-025 � - SR FORM(Golden Rod) <br /> REVISED 11/17/2003 �� <br />