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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> rror-F �020If7 S <br /> OWNER/OPER TOR G4 JZ <br /> _/ - CHECK If BILLING ADDRESS <br /> FACILITY NAME CC��.. �// <br /> SITE ADDRESS <br /> /t <br /> Street Number Dlrectlon G✓ 44 Y StreeWtName Clt ZI Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> ,L <br /> Q S N 171 r {40 'F' Street Number Street Name <br /> CITY C ^ � � STATE ^� ZIP 47 C 2 O <br /> PHONE#1 �! EXT. APN# LAND USE APPLICATION# V <br /> col) — 30 '3'2 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> 0 V ' V` In O CHECK If BILLING ADDRESS <br /> BUSINESS NAME 1 PHONE# EXT. <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 <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: M(iy j C) �t/�aA C�C—Z DATE: 136AC) <br /> PROPERTY/BUSINESS OWNERIO OPERATOR/MANAGER OTHER AUTHORIZED AGENT 11 <br /> If APPLICANT is not the BILLING PARTY proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: 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 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. P <br /> cy —117 <br /> TYPE OF SERVICE REQUESTED: R� �! <br /> COMMENTS: <br /> A114 —1 <br /> J0Q 3° zp2o <br /> F " CA441 <br /> uw C <br /> OUN <br /> HST HD PSR MfNT <br /> ACCEPTED BY: Y1/I EMPLOYEE#: yDATE: <br /> ASSIGNED TO: �r EMPLOYEEM V� DATE: TW '0 <br /> Date Service Completed (if already completed): SERVICE CODE: o� P I ),�Q,5 <br /> Fee Amount: ` r�y-� Amount Paid o Payment Date ! c362D <br /> Payment Type Invoice# Check# Received By: - <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 V,^ n J4o(eO S <br />