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SAN JOAQUIN COUNTY ENVIRONMENTAL HFALTH DFPARTMFNT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER I OPERATOq <br /> C ,v � ) ,` r CHECK If BILLING ADDRESS <br /> FAcxrrY NAME r7 r <br /> SITE ADDRESS v J ,�-- �% <br /> Strost Number n t et am G Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name _-- <br /> CITY STATE zip <br /> PHONE#1 EXT. APN LAND USE APPLICATION# <br /> (z 7 -7 � 1 � <br /> PHONE#2 EXT. BCS DISTRICT LOCATION CODE -� <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR CHECK I PILLING ADDRESS❑ <br /> BUSINESS NAME PHDNE# RE �.�,1 <br /> HOME or MAILING ADDRESS FAx# Ju /vO <br /> CITY STATE gN�jg ZO <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator <br /> E�l �lyf same. <br /> acknowledge that all site and/or project specific ENV IRON MENTA I. HEALTH DE:['ARTwF`r hourly charges assaclat4j8790 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 June)t:i"' <br /> COUNTY Ordinance Codes,Standards,S,T,f-an�F Zi <br /> s. <br /> DATE: �o Z LI <br /> APPLICANT'S SIGNATURE: = <br /> PROPERTY i BUSINESS OWNFR® OPERATOR/NIANAGLR ❑ O'1 HER AvTHORILFD AGFN( ❑ <br /> 1JAPPLIcA,Nr is not Me BILLINC7 PARn,proof ujauthorizatiun w sign is required L+�t� <br /> ,AUTHORIZATION TO RELEASE INFORhIATION: When applicable, 1, 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 envirunmrntal,;itc assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONNIFNNI'AI.HEAt.Til DEPARI'NIEN'F as soon as it is available and at the same Umc It 1N <br /> provided to me or my representative. ----II <br /> TYPE OF SERVICE REQUESTED: <br /> COYIIENT8: <br /> 0 < _,. > F�Irucl"r��'; <br /> Oehl I�c�°�ec� �, ���r�d h;,��� ( ,��. t►�) . > here is -o / <br /> p e l y"'i.i CD,- v�j e l l ---{ <br /> ACCEPTED BY: <br /> EMPLOYEE#: DATE: F. �5 "tJd J_ <br /> G L� <br /> EMPLOYEE#: DATE: <br /> / ----4ft3N*3NE0 TO:viceCompleted (if already completed): SERVICE COOS: 0(rte jplE'unt: ) Amount Paid � d(� Payment Date =%;/ZD <br /> -7� Received By_tType y._ Involve# Check# I tjl <br /> �° F-!"4p 48• ��''•�''✓� T C, rl �I/3'�t L; J I J,'1 J n "') j� ,/ .,_-.� <br />