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�Gr1K c�tr1�. <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> =Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> •,amw. y y CHECK if BILLING ADDRESS <br /> ' ,F-AnLffY NAME <br /> SITE ADDRESS l On <br /> Street Number Direction Street Name Ci Zi Code <br /> HOME or IMLING DRESS If Different from Site Address) <br /> Street Number Street Name <br /> CITY: STATE ('�. 1 <br /> y <br /> PHONE 91 Err. APN# LAND USE APPLICATION#. <br /> O <br /> PHONE#ZT BOS DISTRICT LOCATION CODE <br /> a� <br /> { _ - CONTRACTOR f SERVICE REQUESTOR <br /> C REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> ' MlySINESSNAME � PHONE# ExT <br /> Zisi <br /> NoMEor MAILING ADDRESS FaX# I <br /> 2_5M -, ( 26,) <br /> CITY'- STATE ZIP <br /> 5 <br /> B LIlVG.ACKNLJ�FVi._EDGEMENT: 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 JOAQULN <br /> COUNTY Ordinance;Codes,Standards,STATE and FEDERAL laws. <br /> ATPLICANT S SIGNATURE l�J� DATE: <br /> PROPERTY[BUSINESS OWI,= I OPERATOR[MANAGER❑ OTHER AUTHORIZED AGENT <br /> IfAPPvCANT.is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHOR[ ATION TO RELEASE INFORMATION When applicable,.1,the owner or operator of the property located at the <br /> T— — - -- __- to <br /> — above aslte adrir ss hereby authorize release.of any.and.all results geotechnical data and/or environmentallsite assessment <br /> ITitisrn?Attfln fo the SAN JOAQUIN•GoUNTY ENymONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> --- —---- <br /> „provided tome or my representattve <br /> - <br /> ERVtCE-REQUESTED'— <br /> r- , <br /> 1–WE <br /> 77: RECEIVED <br /> QEC 12 2912 <br /> SM <br /> "Gum COU <br /> ROMENTAL <br /> r7 - yy11LTl6ip �011EitIT <br /> ACCEPTEDBY.J EMPLOYEE#: DATE: �/ <br /> EUPLOYEEV:.. DATE <br /> Date•Ser>Jice-completed. (if already completed): SERVICE CODE: P/E: <br /> x <br /> ee�Alnount Amount Paid Payment bate <br /> t 't b., tt h. • - .Y_It_. Av t + , ' + tt :' i+.. + 4 <br />