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SAN JOAQUI.OUNTY ENVIRONMENTAL HEALTH DEPARTMENT ARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOR / ,i^^ CHECK if BILLING ADDRESS <br /> CSG t-v v�� f°'q�t�t f�� co <br /> FACILITY NAME <br /> K ; �r v Q 11 Sls/lo �t Z�3 �// <br /> SITE ADDRESS �s �! G'y , eyGY <br /> Street Number I Direction Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) e5'001 ��oC-(�j�Jr Gyle <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> N# LAND USE APPLICATION# <br /> (9111 F�eZ1,5`ZZ PHONE#1 EXT AP <br /> PHONE#2 ExT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRSS <br /> BUSINESS NAME PHONE# ExT• <br /> HOME or MAILING ADDRESS FAX# <br /> CITY �, STATE C L°/ ZIP <br /> T l <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 <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: DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERAT NAGER ❑ OTHER AUTHORIZEDAGENr / tiG+ G/'i I/�tt �L✓/� <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. Ncc <br /> TYPE OF SERVICE REQUESTED: C i' �, � �'" JL?CC T <br /> COMMENTS: PR 0 <br /> W AZO <br /> AD ?0 <br /> 13 <br /> N "NgQVtNFAUN� qv'r4,ONT <br /> ACCEPTED BY: t/}/�r �rt EMPLOYEE#: DATE: Q <br /> ASSIGNED TO: T �f ` EMPLOYEE#: DATE: b <br /> Date Service Completed (if already completed): SERVICE CODE: t PIE: Z3O <br /> Fee Amount: 3`� Amount Paid 37TJ Payment Date S D <br /> Payment Type Invoice# Check# oZ� �� Received By: <br /> EHD 48-02-025 SR FORM(Golden R J/ <br /> REVISED 11/17/2003 , ``lam <br />