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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> WNER/OPERATOR <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESSJ -I - /� '�l ` 'lqy <br /> Street Number re reel Name i CO o <br /> HOME or MAILING ADDRE�I (IfFifferent from Site Address) <br /> q'4 !t' I f A a `C 4-- Street Number Simi Nam. <br /> CITYr e_ STATE ZIP <br /> � <br /> PHONE#1 EXT. APN# LANDUSE APPLICATION# <br /> (�ql l z <br /> PHONE 92 En. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR 12 <br /> & `��ye- CHECK If BILLING ADDRESS <br /> BUSINESS NAME C �O/^ PHONE# EXT. <br /> HOME or MAILING ADDRESS Fax# <br /> 7 Al 2 dw-ocgo 54- ( ) <br /> CITY d-�.-Y STATE -,A zip Cl S 2 <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 /> 1 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:, A 4�Q5 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> /fAPPLiCANT 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: -f�3a J I/1.L ()l/\, <br /> COMMENTS: <br /> Vie <br /> AUC 0 20 <br /> HJ0AQU/lV 20 <br /> �CTk pEP"C01 N7-y <br /> ACCEPTED BY: UI�MY 0 EMPLOYEE M DATE: <br /> ASSIGNEDTO: A^ ,� EMPLOYEE DATE: v <br /> Date Service Completed (if already completed): SERVICE CODE: 'PIE: I(jJ 3 <br /> Fee Amount: �- tc, -Z Amount P - ��� b Payment Date 1 2LD <br /> Payment TypeC/L Invoice# Check# —� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />