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SAN JOAQUI COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type o Business or Property FACILITY ID# SERVICE REQUEST# <br /> I <br /> I I .M- h-0 EA (AO-7: -- 0 q <br /> OWNER/OPERATOY�tfl� <br /> _ CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SITE,ADDRESS <br /> //���p�jjj 61 <br /> f/,J/ 4mkIX.- <br /> HOME <br /> /�/ Street Number i�'rection et Na Zi Code or MAILING ADDRESS JJ��(If Different from t Address) <br /> 'C.JU Street Number Street Name <br /> CITY � T STATE �� ZIP <br /> dncPHONE#'1 EXT. APN# / LAND USE APPLICATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR InAu CHECK If BILLING ADDRESS <br /> BUSINESS NAME ' d/1 M,6,q/I t/')) - PHM1O E�) �jJ P EXT. <br /> I�""h <br /> �) <br /> HOME or MAILING � air'/DDRESS > / I FAX# ) �' <br /> CITY STATE <br /> t <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 appli ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, S A E and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: N C Wy DATKL / V �s� <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: (.C-5'r— AG?�AFc'T PAYMENT <br /> COMMENTS: RECEIVED <br /> OCT 14 2005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: L L t EMPLOYEE#: 0 3 DATE: /D 14/0.5 <br /> ASSIGNED TO: J4 EMPLOYEE#: 'E3 Tq <br /> DATE: <br /> Date Service Completed (if already complet SERVICE CODE: t PIE: 2 3O <br /> Fee Amount: 4-�� Amount Paid r. Payment Date <br /> Payment Type Invoice# Check# I D 3 Received By: <br />