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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> ::IR-, 00;-<3-367 ( <br /> OWN RItOPERATOR <br /> Puy- k l CHECK If BILLING ADDRESS❑ <br /> 1. -7 <br /> FACILITY NAME <br /> SITE ADDRESS ` ('�vq1 EL .�r�1��y" C � S <br /> 31 ` Street Number Olrectian Street�n �O NamaJ cityN ZI�Co <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> � <br /> i <br /> . Street Number Street Name <br /> CITY STATE <br /> PHONE#f Ex' APN4 LAND USE APPLICATION <br /> 3-304 <br /> PHONE#2 EKT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SER-VI('F REQ1X1STOR <br /> REQUESTOR f..{ I�` 6�� ( v CHECK If BILLINGA0DRE55❑ <br /> BUSINESS NAME3(' PHONE# 3 U ExT• <br /> u J o2c <br /> HOME or MAILINSS <br /> G REFAx# <br /> MKI cZ !�ve ( ) <br /> CITY f , STAT zip S-5 <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 I also certify that 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 FEDE kf l ws. <br /> —APPLICANT'S SIGNATURE: DATE: -� <br /> PROPERTY/BUSINESS OWNE[� OPERATOR/44ER ❑ OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY proof of authorization t0 sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property t NT <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmentalZAPINN <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as Soon as it is available and at the S t <br /> IRED <br /> provided to me or my representative. 021 <br /> TYPE OF SERVICE REQUESTED: I J/ SQL <br /> COMMENTS: SAN JOAOU OUNTY <br /> ENVIRONM NTAL <br /> HEALTH DE PA TMENT <br /> ACCEPTED BY: I A C EMPLOYEE M 1 DATE: q v <br /> ASSIGNEDTO: V ri` v EMPLOYEE#: 33rn DATE: 2 2- <br /> Date Service Completed (If already completed): SERVICE CODE: L1, PIE: U� <br /> Fee Amount. (� •(�(� Amount Paid / S2 Payment Date 3 a <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />