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SAN JOAQUIN UNTY ENVIRONMENTAL HEALT PARTMENT <br /> IL SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATO <br /> ' � � �^O ` ! CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME �J <br /> 118 <br /> SITE ADDRESS 3 S 5 C�rt�tY1 F C_ <br /> Street Number Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 0. ��x cv, <br /> Street Number Street Name <br /> CIN CC)X-\(- C\ STATE ZIP 'I LIS2 Ll <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> 01 ) y-1-� _3V,C <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> (ft) y 23 -- 3S <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME �•J iJ PHONE# ExT. <br /> OL <br /> y <br /> HOME or MAILING ADDRESS FAX# <br /> O(YJ 1 y 61 63y 2 <br /> CITY -yam,,C STATE 0 0'� ZIP 6'1's-) a� <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standar s, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: ft , , DATE: ' 2 -7 6 ©`1 <br /> PROPERTY/BUSINESS OWNER❑ PERATOR/MANAGER El OTHER AUTHORIZED AGENT <br /> If APPLICANT is ofJth &LLING 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 /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> F''1,11 UNN <br /> SAN JOA oNMENTA►- <br /> NepL H pEPARTMENT <br /> ACCEPTED BY: O f t /�t � - EMPLOYEE#: 0 DATE: u <br /> ASSIGNED T0: lLe' EMPLOYEE#: _35V DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: iq r P/E: <br /> Fee Amount: ', �a Amount Paid Payment Date oZ� Lf <br /> Payme :ZE7 <br /> nt Type �. ' Invoice# Check# Received•By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />