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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- <br /> OWNER/OPERA OR Ir „ <br /> CHECK If BILLING ADDRESS <br /> 111 v , l 6"- <br /> FACILITY NAME <br /> C CYt Cer <br /> SITE ADDRESS i C� <br /> Street Number Direction `�' '' treet Name Cit ` Zi Code <br /> HOME or MAILING ADDRESS (If Differetit-from Site Address) <br /> L U V <br /> 4— Street Number Street Name <br /> CITY �� STATE ZIP i���—•1 <br /> C1 pC <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> r <br /> ONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEA PHONE# EXT. <br /> � 6 � o r V aC- z2i 2 - 6z� <br /> HOME or MAILING ADQRESS ,( FAX# <br /> / CO 1 l l ) <br /> CITY *�G, STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: 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 /> 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: d--r—j DATE: l � <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR MANAGER ❑ 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. p <br /> TYPE OF SERVICE REQUESTED: 'I U Re <br /> COMMENTS: <br /> Af4y 3 <br /> VAA(t l'1�L'� N NV�o UtN Co�Zp <br /> E`I CTy�FpgR��� <br /> ACCEPTED BY: EMPLOYEE M q DATE: <br /> ASSIGNED TO: C /n Ille EMPLOYEE#: DATE: GjJ /�j •Z <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: <br /> Fee Amount: I ` GV Amount Paid Payment Date <br /> J <br /> Payment Type Invoice# Check# ,eceive'd By:%./ <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 (�/ <br /> � <br /> r�05 �6 UU <br />