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0AIN JUAQLAN%,UIUNTYL+NV11tUNiVIEN'1'ALJt1LAUfH11E1'AICfMENT <br />• • SERVICE REQUEST �. <br />Type of Business or Propertyrf� SERVICE REQUI <br />OWNER/ OPERATOR <br />ZL / CHECK if BILLING ADDRESS <br />FACILITY NAME fe i7 •t/ / <br />w <br />SITE ADDRESS <br />I6 � 2- W�/�//�1.�� .lam L-�} �✓� S /d c 1� %�.�/ � yZ�� <br />Street Number Dlreetlon Street Name cityZI Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />CITY STATE ZIP <br />PHONE #'I ExT• APN # LAND USE APPLICATION # <br />3'j7J <br />PHONE#T ExT• •.BOS DISTRICT ��`"'�iyrr s��,-, =: ;LOei-nai CODE +"P's� <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />�'ir( vvv <br />CHECK if BILLING ADDRESS <br />BUSINESS NA4E <br />PHONE # E'R• <br />M✓P a <br />IK - <br />HOME or MAILING ADDRESS <br />FAX # <br />?a P z 8 <br />( ) <br />CITY (rs� <br />STATE ZIP 4717L <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, Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Y�iV 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 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: • Q <br />COMM�NTS: U OF <br />PAY M E NT <br />RECEIVED <br />