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;,-r ;inti p-AIa0a� <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or property AC1L'ITY.`IQ;.# S/E�RVICEREQUES':#. <br /> OWNER/OPERATOR <br /> GHECK 1f 13ILLING ADDRESS <br /> FACIN <br /> fff Y" <br /> SITE ADD�Ess Z E ;,�� 53Z <br /> Stmat Number Dt action tet Nem9 c, ZI Code <br /> HqtaF or MAlu,2G ADDRESS (If Different from Site Addross) <br /> Street Number Etre mama <br /> CITY 'STATE zip <br /> LH0N€#1 APf1 LAND USE APPLICATION <br /> ( 1 <br /> PHONI=#2 EXT' 'EIOS"Dts-mict •,y•i= LOCATION 0009'+' <br /> CONTRACTOR/ SERVJCE REQUESTOR <br /> REQU ESTO R <br /> Git!_CK If 61LLI14G ADDRES <br /> USINESS NAME <br /> � pwnvc-y <br /> ,f r, Exr. <br /> • � <br /> HOME.or AILINGADDRFs-A <br /> 097 6— <br /> CITY •'-" ' STATE. ZIP <br /> BILLING ACKNO'%VLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENvIRONymNTAL HEALTH DLeARTMENT hourly charges associated with this projoot <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 JoAQwN <br /> CouNTY Ordinance Codes,Standards,STA'L'E and PF.DERAL laws. <br /> APPLICANT'S SIGNATURE- DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER CI ER AUTtIORtzeD AGENT❑ <br /> IfAPPL/CANT Is not the B/LLI r..PARrY.proofofauthorization to sign is required 1 idle <br /> ACJ 1'HORT2ATION TO REL]EASIJ INFORh1ATI0IY: 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 environmentaVsite assessment <br /> inforMation tO the SAN JOAQUIN COUNTY ENVIRONaNSNTAL HEALTH DEPARTMMiT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERvicE REQuESTEA: d j <br /> coNazlllsHrs:�. � 1 ����1YJ + � ��� RECE�V_D <br /> &A Ws- 6r�l 10 4 Z004 <br /> �� AUG <br /> 1W. <br /> SAN JOAQ No TM <br /> AL <br /> ME <br /> :... <br /> ENT <br /> ATE: <br /> At?PROirEI7.L'1': <br /> . TM <br /> . <br /> ,4u61fahEEDrTO`. Igo <br /> EddP.t oYEE :. DATE: <br /> Date::5er <br /> lee"O.m letedr'tf'al'rt ad' orlipJeted};,,. .. , <br /> :,, . .. . .:SERv10ECobE: •p;�E:,;, <br /> 'l`eeAmaa"rid;'. Amount Paid -? Payment.Date' o' <br /> g <br /> .Invoice#"::' a 6hetk'# :Received,•B <br /> :f ayment`TYPp'� .. Y:; <br /> EHD a8-01-025 SERVICE REQUEST FORM �� <br /> REVISED 6-5-02 %K <br /> SQA <br /> 10 800-1d HIAIA 9Pt; 'R4br.1'A7 C7 '7r <br />