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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# c SERVICE REQUESSST�# <br /> ALCM' `T!�.Zv� SC Flv� `-��j"�� �"✓�� <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRESS❑ <br /> aN-c,.c ;;rJ•,r1E� Sctl��- �.s��t�1i <br /> FACILITY NAME <br /> SITE ADDRESS <br /> ILIU00 A�sT 1 -J 2opt� IAA�ECA S331D <br /> Street Number Direction Streot Name city Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> PC) ' L Street Number Street Name <br /> CITY STATE ZIP <br /> MA�-S E C4 1,5-33(o <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> Ut"4 ) 3L„c 2-0(0- loc oS v <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Exr' <br /> MC 12 t� /LIN( ?�I L3 -U-2- <br /> HOME or MAILING ADDRESS !� FAX# <br /> 12-L12- 17ut O.�i (;;v,c� ( Io", ) �3 :5931- <br /> CITM MA :FC A STATE Cf} ZIP 9 Is;33 <br /> / <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: X"� �� DATE: / Z-Z <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT C lel 11. fs-n1CIIt-it_ <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. I" <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: JLIN 0 <br /> 3 <br /> SA N�AQUItVHFqLT ��A <br /> V??1N 4D2Lp <br /> Nr <br /> ACCEPTED BY: EMPLOYEE#: DATE: 3 •ZcZ0 <br /> ASSIGNED TO: lI�,I EMPLOYEE#: DATE: C 3 Z aLb <br /> Date Service Completed (if already completed): SERVICE CODE: S P/E: '160 <br /> Fee Amount: �,Og Amount Paid tP 0x Payment Date /P 3 Z<] of <br /> Payment Type Invoice# Check# 37T2/U Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />