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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST r5 26-7 <br /> j 1 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> S� 6g3;o �' <br /> OWNER 1 OPERATOR <br /> Y , CHECK if BILLING ADDRESS O <br /> FACILITY NAME U v W C-- <br /> SITE <br /> .-- <br /> SITTE�ADDRESS �G t " 'e <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) t>_1� <br /> 8 V 3 Street Number (J+ Street Name <br /> CITY STAA <br /> CA— ZIPq <br /> PHONE#1 Err. APN# LAND USE APPLICATION# <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REt1UESTOR VA nkfa <br /> `` —;:<,D <br /> �_ CHECK If BILLING ADDRESS <br /> BUSINESS NAME L'4-M ro PHsta - 8pS !q e <br /> HOME or MAILING ADDRESS FAx# <br /> rE <br /> TY "tvr— STATE ZIP -Zd� <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 Codec,Standards, ST TE and FEDEMIJaws. <br /> PPLICANT'S SIGNATURE: kks DATE: <br /> PROPERTY/BUSINESS OWNER 13 OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICANT is not the BILLING PAR TY,proof of authorization to sigh 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 availabP �iTne time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: U S <br /> COMMENTS: <br /> EOENLTM <br /> ENVIRONMENTAL <br /> OI p HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: -5 DATE: <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P I E:J(P-02_ <br /> Fee Amount: '/`(� Amount Paid l S Z r Payment Date ) <br /> Payment Type L �-� Invoice# C # LL L '�- 33 d 3 Q Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />