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f <br /> SAN JOAQUI 'OUNTY ENVIRONMENTAL HEALT EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> s OWNER I OPERATOR <br /> / CHECK If BILLING ADDRESS <br /> ft FACILITY NAME <br /> SITE ADVO <br /> 7 Street Number Direction Street Name City_ Zi Code <br /> HOME orMAILING ADDRESS <br /> p (if Different from Site Address) < <br /> /'l/• 1f laW Street Number v Street Naa <br /> SZfi' fi <br /> STATE zip <br /> CITY/%/,�Al5:� 0.133 <br /> PHONE#t Ext. APN# LAND USE APPLICATION# <br /> ( '00f) 0`24-07S4 41149-D/ <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( 9 12�S 3aCp Q <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Q /J�l���f.a�f � �f f•v G �� �,c 1* CHECK If BILLING ADDRESS C� <br /> BUSINESS NAME /�� PHONE# Ext. <br /> HOME or MAILING ADDRES§ FAx# <br /> "';;'e_ d (2 a`!) 3335 — f3 3 0 3 <br /> CITY /a'e.21 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 HEALTn 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 applicoicYa t the work to be per rmed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Cortes,Slandards,ST ' G TED• L <br /> APPLICANT'S SIGNATURE: - f DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR I MANAGER ❑ OTHER AUT'IIORIZFD ACFNT <br /> If APP/.ICANT is not the BILLING PARTY,proof of authorization to sign is requi e I Tule <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 tine SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the some time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: LAi d. <br /> COMMENTS' <br /> RECEIVED <br /> AUG 2 7 2003 <br /> ,J SAN JOAOUIN COUNTY <br /> APPROVED BY: D K� �` EMPLOYEE M. d9� R {ONMENTAI H DI -� <br /> ASSIGNED YO: Dv �� r EMPLOYEE M. D�r/ DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: L'a�, PIE: a <br /> J <br /> Fee Amount: -117 (� Amount Paid 22 Payment Date 1062-72 D <br /> Payment Type / Invoice# Check# Aeceived Ely:&a <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />