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0A1N JUAtlUIiN S V UN I Y L'1N VIKUIN1VILINTAL nEAL'I N EVARA MEN't <br /> SERVICE REQUEST <br /> =Peof Business Proper` FACILITY ID# SERVICE REQUEST# <br /> '4�a :1l 5 <br /> /� a) <br /> O N /OPERATOR (160AAL <br /> CHECK if BILLING ADDRESS❑ <br /> FACILITY kM <br /> SITE ADDRESS <br /> 6�( 3 Street Number I Direction Street Name � it /(/ ZIv Code <br /> HOME or MAILING ADDRESS (if JDiifferent from Site Address) <br /> 5'745' <br /> Street Number Street Name <br /> CITY ` '-/ ESTATE ^' —A 6 . ,7fll~a�y <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> `f - b3% <br /> PHONE#2 EXT, BOS DISTRICT LOCATION CODE <br /> (366) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR ��✓' V ��J I' I <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME � � �U PHONFJ �1 [ V J� EXT. <br /> HOME or MAILING ADDRESS FAX# yz <br /> CITY ,,{.�,., , SAT 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Stand( ds STATE and FEDERAL laws. � <br /> APPLICANT'S SIGNATURE: IWt_� <br /> DATE' <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 env ironmental/site__ass ssment <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. ,) R41,44, "I <br /> TYPE OF SERVICE REQUESTED: 1/ , kc � �i <br /> COMMENTS: — <br /> O ED <br /> ,/g GL0~ G2S}/�/ "�2G � �. "�G �V <br /> v/� s-/�/� �� /Z/�`� > MAY 15 2003 <br /> rr�� � —edo L(r !/3— !16 .st,�;�"°—tW+t. <br /> SAN JOAQUIN COUNTY <br /> PUBLIC HEALIH SERVICES <br /> ENVIRON'''.:NTA[ HF�I_TH P)VISIO. <br /> APPROVED BY: - EMPLOYEE#: C/� r DATE: <br /> ASSIGNED TO: (� EMPLOYEE#: DATE: <br /> 13 1 <br /> Date Service Completed (if already completed): SERVICE CODE: / 67 1 P 1 E: <br /> Fee Amount: Amount Paid Payment Date 5 3 <br /> Payment Type Invoice# Check# Receive By: <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />