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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> -rte- <br /> rV L44- . 4A-4\-J e-q `7 2 1 —�5q5 qI`4 7 <br /> OWNER/OPERAT R <br /> CHECK if BILLING ADDRESS E] <br /> FACILITY NAME <br /> SITE ADDRESS 2370 ' �$raud!T Rc✓ �r�a/� /52�� <br /> Street Number Direction Street Name City Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> 20 Street Number Street Name <br /> CITY STATE ZIP <br /> / Cg G --S <br /> PHONE#1 ExT APN# LAND USE APPLICATION# <br /> (Zoe) 9'93 - 06 q 2 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# ExT• <br /> OZ - <br /> HOME or MAILING ADDRESS FAX# <br /> CITY STATE ZIP <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,ST and FEDERAL 1 <br /> APPLICANT'S SIGNATURE: DATE: <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. n <br /> TYPE OF SERVICE REQUESTED: ,�v L [ U 4 S - J'c �s�J C _ /� t A-t-)Lt-4-C- <br /> COMMENTS: RECENEDG( (, —� <br /> JAN 1 1 2006 <br /> SAN JOAQUIN COUNN <br /> ENVIRONPAR MENT <br /> ACCEPTED BY: OL—tV Ctrl l EMPLOYEE#: O3Z, DATE: <br /> ASSIGNED TO: Le L . EMPLOYEE#: 6up 3'j DATE: l t <br /> Date Service Completed (if already Completed): SERVICE CODE: 5'-2_2_ P I E: t <br /> Fee Amount4 Amount Paid - Payment Date Ll <br /> Payment Type ✓ Invoice# Check# Lf3 Received By: <br /> EHD 48-02-025 SR FORM(Golden'Rod) <br /> REVISED 11/17/2003 <br />