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u SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> fA 03 1Z_S I 'i4- Ga- 00 3I <br /> OWNER/OPERATOR C— cq 1( I�c`� Cr11�,, <br /> vl L .� �-� SL�s vl S 1 Oi CHECK if BILLING ADDRESS <br /> FAciLITYNAME C1 {i V—A J '?vZ0 r t4CZ- 4 <br /> SITE ADDRESS �� �G t 1,�l � S�.�i�t To <br /> Street Number Diraetlon r '`1 1 Street Name Cit Zip Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> v Street Number 1`�1 Street Name I <br /> CITY C��r]�,J��, STATE � Zip <br /> PHONE#t J l ExT• APN# LAND USE APPLICATION <br /> (W) ) 2q7- - UUQL <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# Ex-r. <br /> HOME or MAILING ADDRESS FAX# <br /> 1 ) <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: f,4� DATE; Ol— 01;`ZO <br /> PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> Iff1PP icAivT 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 avai td at the same time it is <br /> provided to me or my representative. E <br /> TYPE OF SERVICE REQUESTED: ��}� ` mat l�S G!��� VZ6 <br /> COMMENTS: (!5 2DZ, <br /> o�lN�ou <br /> D pM NT <br /> ACCEPTED BY: \ EMPLOYEE#: DATE: �1 Cl- <br /> ASSIGNED lJLJ <br /> TO: \/ EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: O( ` P]E: �( <br /> Fee Amount: �w l(;a Amount Paidoz:) Payment Date / S <br /> Payment Type Invoice# Check# Received By: <br /> v v <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />