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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER l OPERATOR CHECK If BILLING ADDRESS❑ <br /> FACILITY NAME " �C) C ! 1 x n <br /> SITE ADDRESS �-1 ?r Lj 1/ty a } � - 1 Ll��r„Street Number ion [ ' 1VStreet Name, \ Cit DlJ Zi Code Jv <br /> HOME Or MAILING ADDRESS (If Different from Site Address) , Z <br /> Street Number /�/ Street Name <br /> CITY ,V C ti>S TE <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> so <br /> PHONE#2 Ex-r. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR 1 SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAMEExr. <br /> E5 Q l� �p l P 1 * <br /> HOME or MAILING ADDRESS FAX# <br /> �2'7:,- IV L—A-U t2-C"Z1 5'1 { ) <br /> CITY 5rT— C—I.<-rT-b -%J <br /> ` STATE Q 1 ZIP S^�0 <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 thislication and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standard. ST TE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 02/o( L I BUSINESS OWNER® OPE.ZA79R/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 the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: D lt I lu 1A I DA <br /> COMMENTS: EA <br /> Ck nit t P FFe o <br /> mfr Z�?1 <br /> �iylyrqQU/N C <br /> NrH ACCEPTED BY: 1 EMPLOYEE#: DATE: 2 <br /> ASSIGNED TO: wumi EMPLOYEE#: !�c DATE: 2 �7 <br /> Date Service Completed (if already completed)): SERVICE CODE: P E: ` r] <br /> Fee Amount Amount Paid ')dJ ,ate• Payment Date { v <br /> Invoice# ab Receit►ed By: <br /> Payment Type C <br /> EHD 48-02-025 ' <br /> SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />