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SAN JOAQUwOUNTY ENVIRONMENTAL HEALT*PARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> � CHECK If BILLING ADDRESS <br /> FACILmNAME <br /> S Ess rl �,, N • Y'(1�t_1nae1_. �J- Cs3.cr.�.•S - rescan Camp g53Zi <br /> treat Number Di Street CKV rie <br /> HOME or MAILING ADDRESS (ff Different from Site Address) <br /> Street Number me <br /> CITY STATE zip <br /> PHONE#t EXT. APN LAND USE APPLICATION <br /> M9 ) y - 437 <br /> PHONE#Q EXT- BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHOHE# EXT' <br /> HOME or MAILING ADDRESS FAX# <br /> (20 ) <br /> CITY Le�A, STATE ZIP Cl <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 <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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT 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 1 the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/siT <br /> information to the SAN JOAQuIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at theNOV <br /> pie ItD <br /> provided to me or my representative. NO�/ <br /> TYPE OF SERVICE REQUESTED: f1 G - <br /> SAN��AA 446. 1� <br /> FY <br /> ciorIMENTs: �1 Sx c oj— ne W M1 S v Yh S�soc 4 f1 ryp�'�C'11� c^A".e�>✓�. `mac, 4�paIV/Wg4 111 <br /> �ovn�1 �-o be, .bc,c� cA vr:r�o..l O►�crva�l. Min.T© �-- �r-r:-�.e.s�I,�>� <br /> W:�-t- �r sTc�L` �-c�e Re�,J l.A1,S ♦ <br /> k.%93 bJ:CA 'C)e.',So t" • Ste 0cN'Z4c``�n <br /> S � <br /> AC!71BY <br /> : EMPLOYEE#: ���� DATE! <br /> ASSIG T ��� ; EMPLOYEE#: /J/ DATE: <br /> Date Service Completed (if alrea6 completed): SERVICE CODE: P I E: ,3� <br /> Fee Amount: 60 0 Amount Paid 3 Payment Date 2 O <br /> Payment Type Invoice# Check# 2 q L-V Received By: 112s-- <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />