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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Tyke of Business or Property <br />��AO �,- /'AfZ- CHECK if BILLING ADDRESS <br />r <br />BUSINESS (NAME t-:�DIG-Ag- -T- A;5D(,IA77i�-� <br />FACILITY ID # �� —> <br />SERVICE �RREEQUEST # <br />FAx Q#/ #_6) I� j <br />r x/imo <br />CITY STATE ZIP it <br />ACCEPTED BY: <br />(� ((% ( <br />I.CM6 <br />OWNER/ OPERATOR 1 r J e, <br />` <br />IF/V� Ir\ <br />^� <br />f ` 11LYJY <br />CHECK if BILLING ADDRESS ❑ <br />FACILITY NAME <br />::±ATE: <br />EMPLOYEE #: (E: <br />SITE ADDRESS 3 b70 S "TL 4 .4 Lret <br />-Y„-� <br />Street Number ection <br />Street Name <br />i ode <br />HOME Or MAILING ADDRESS (If Different from Site Address) <br />r4 <br />1P) <br />Street Number <br />,tri) <br />Stre�dwe <br />CITY <br />r �r� <br />STATE ZIP <br />PHONE #1 EXT <br />APN # <br />Received By:� <br />LAND USE APPLICATION # <br />_ Exr. <br />PHONE #T . _ <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR 4—IZ--% J <br />��AO �,- /'AfZ- CHECK if BILLING ADDRESS <br />r <br />BUSINESS (NAME t-:�DIG-Ag- -T- A;5D(,IA77i�-� <br />7 Z,,)OEXT* <br />HOME Or MAILING ADDRE �) S ^ �n <br />FAx Q#/ #_6) I� j <br />r x/imo <br />CITY STATE ZIP it <br />' W � <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 or <br />activity will be billed to me or my busi7TAI;E <br />as identified on this form. <br />I also certify that I have prepared this cation and that the wv to jyj� e be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Standards, and FSR J�v . � J <br />APPLICANT'S SIGNATURE: <br />PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />tri / a4� <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br />�bove 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. PAYMENT <br />TYPE OF SERVICE REQUESTED. S� 10C- A�N C- -f E -c <br />� � ��%� M ! <br />COMMENTS: <br />p c� <br />MAR 2 7 200 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />ACCEPTED BY: <br />(� ((% ( <br />EMPLOYEE #: <br />2:7 VASSIGNED <br />TO: <br />A4 -E �S <br />::±ATE: <br />EMPLOYEE #: (E: <br />j Z"1 ()b <br />Date Service Completed (if already completed): <br />SERVICE CODE: S Z2� <br />P 1 E: <br />Fee Amount: <br />ec' ,,oi) <br />Amount Paid <br />,tri) <br />Payment Date <br />3]>-7 ( o (o <br />Payment Type <br />Invoice # <br />Check # <br />Received By:� <br />EHD 48-02-025 SR FOERM'(oil 8n`Rod) <br />REVISED 11/17/2003 <br />