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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST p (z o 1 ,03--7 61 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> \O CHECK if BILLING ADDRESS <br /> FACILITY NAM _ <br /> SITE ADDRESS TT�2ttC �(L a <br /> LV StreetNumber Direction Street Name Cit Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE zip <br /> _i <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> G1 t <br /> PHONE#2 E.. BOS DISTRICT 11 LOCATION CODE <br /> D041 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> n �^c CHECK if BILLING ADDRESS <br /> BUSINESS NAME �T\` PHONE# ExT. <br /> HOME or MAILING ADDRESS FAx# <br /> ( ) <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 /> 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: ��(j� V DATE: W M I Z 1 <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 %9,ime time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: /vC <br /> COMMENTS: cA.. 1 <br /> "W 3 20 <br /> h ROHMC OUty�, <br /> H�FPgR MINT <br /> ACCEPTED BY: } I EMPLOYEE#: DATE: �Z <br /> ASSIGNED TO: l Y 1 EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O P/E: 2 <br /> Fee Amount: Z Amount Paid I J�.� Payment Date I 3 2- <br /> Payment <br /> Payment Type r Invoice# e # 2� �I Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />