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NAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST Alk <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 614-1; <br /> OWNER/ 073"'OR <br /> CHECK If BILLING ADDRESS 171 <br /> FACILITY NAME AA,167— '164P <br /> SITE ADDRESS -270 <br /> Street Number Direction Street Name ~l 'v city Zip Code <br /> HOME Or MAILING DDRESS fIfferefrom Site Address) <br /> tt7��77� Street Number Street Name <br /> CITY i j TATE IP <br /> u 1/-�' u <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ,33 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT. <br /> HOME or MAILING ADDRESS FAX# <br /> ( ) <br /> CITY STATE ZIP <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 or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this ap 'cation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, TE and FEDERAL 1 S. <br /> APPLICANT'S SIGNATURE: 'tom, DATE: / 7 <br /> PROPERTY/BUSINESS OWNER❑ t OPERATOR/MANAG^ 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 /> 7 <br /> TYPE OF SERVICE REQUESTED: Sf e3WRF "EeVEC� <br /> COMMENTS: 5�p 1 <br /> 1 2007 <br /> SAN JOAOUIN COUt4 <br /> ENVIR DEPARTMENT <br /> HEALTH <br /> ACCEPTED BY: // EMPLOYEE#: 3 DATE: <br /> ASSIGNED TO: EMPLOYEE#: / DATE: <br /> IV <br /> Date Service Completed {if already completed): SERVICE CODE: 'OH P!E: <br /> Fee Amount: 0 Amount Paid q� c-D Payment Date Z 0-7 2 <br /> Payment Type Invoice# Check# ;4f 03 Received By: <br /> EHD 48-02-025 SR FORM(Golden Red) <br /> REVISED 11/17/2003 <br />