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SAN.TOAQ�COUNTY ENVIRONMENTAL IUALT• T)EPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER 1 OPERATOR a.. 15-� <br /> CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> l`; <br /> SITE ADDRESS <br /> 23u14h �. Ti� <br /> las <br /> Street Number Direction Street Name C' Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#7 EXT. APN# <br /> LAND USE APPLICATION# <br /> { J <br /> PHONE#`L ExT. BOS DISTRICT LOCATION CODE <br /> { <br /> CONTRAC'T'OR / SERVICE REQUESTOR <br /> REQUESTQR <br /> CHECK if BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> ROME or MAILING ADDRESS FAX# <br /> CITYSTATE 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 ENvrRONMENTAL HEALTH DEPARTMLENT hourly charges associated with this project <br /> or activity will be billed to we 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: � � yC _ DATE: p y' <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I, C'r �1�i�e. ,C <br /> if APPLICANT iS not the B1LLflVG PAR Proof of authorkw1on 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: <br /> COMMENTS: I ! �� PAYMENT <br /> V RECEIVED <br /> APR 14 2909 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> ACcEPrED BY: EMPLOYEE M DATE; r <br /> ASSIGNED T0: EMPLOYEE#: ON t1f DATE: <br /> Date Service Compl (U already completed): SERVICE COM <br /> Fee Amount: •Z Amount Pald a!© Payment Date70 <br /> �Recelved <br /> PaymentType V Invoice# check## a9By: <br /> EhDREV SED 1111 SR FORM Golden Rod <br /> REVISED 71117!2003 11;10 <br /> { � <br />