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SAN JOAQUIN COUNTY ENvimoNMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> � �3o 12551 O0'RLA z�l <br /> OWNER)OPERATOR <br /> CHECK It BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS t Yosewl-Htf Ne L <br /> Street Number I DIrectlon Street Name +Cit Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) Tp S�Q,y oU 0h <br /> Street Number Street Name <br /> CITYIn STATE 1n ZIP ^53-3 7 <br /> PHONE#1 G(/` ExT. APN# LAND USE APPLICATION# (� <br /> 000 6-76 - L1 3? 2212 SLA <br /> PHONE#2Err• BOS DISTRICT LOCATION ODE <br /> 1 �l7 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR X <br /> (( CHECK If BILLING ADDRESS <br /> �� PH E# �T• <br /> BUSINESS NAME q� 7 <br /> HOMEor MAILING DDRESS FAX# <br /> 0603-3 oS y- ( 1 <br /> CITY e(251, STATE ( ZIP X33 <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 ap lication and that the work to be perfo ed will be done in accordance with all SAN JoAQuIN <br /> COUNTY Ordinance Codes,.Standards, TATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: !g 2 <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/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 anlp Ahe�lave.tir it is <br /> provided to me or my representative. RECEIVED GIY <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: U /� �l l <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: DATE: GI Zd( 7 <br /> ASSIGNED TO: EMPLOYEE#: DATE: 1 <br /> Date Service Ctaiinpleted (if already completed): SERVICE CODE: W PIE: <br /> V <br /> Fee Amount: I J2J Amount Paid 4 G 5 Z — Payment Date <br /> Payment Type Invoice# C ck# (-3 J 2�, �� Received By: <br /> EHD 48-02-025 SR FORM(Golden Rad) <br /> REVISED 11/17/2003 <br />