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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property LL FACILITY ID# SERVICE REQUEST# <br /> 'tqCGt' /irxe-n <br /> OWNER/OPERATOR CHECK if BILLING ADDRESS O <br /> FACILITY NAME / <br /> SITE ADDRESS L <br /> StreeOOt Number Direetlon StreelN Ct ZipCode <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Sbaet Number Slreet ame <br /> CITY STATE ZIP <br /> PHONE#1 E'Ir APN# LAND USE APPLICATION# <br /> (M) 3&q-O7J <br /> PHONIER Em BOS DISTRICT D� LOcA QN CODE <br /> ( ) G <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR // ,(�„ / // /d T. CHECKif BILLING ADDRESS® <br /> �/ /J PHONE# E�'' <br /> BUSINESS NAME ( • /I 'J C,^/ 2 D� <br /> HOME or MAILING ADDRESS (�/0�� //' { �/G N/J C. F'ix# /O J <br /> CIT' o✓-e (f/, L-tL STATE Zip 95& 7e- <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 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. 1 <br /> APPLICANT'S SIGNATURE: � Lld /Dtiz2 DATE: J✓� �v2����� /Y <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER❑ OTHER AUTHORIZED AGENT q!,! <br /> IfAPPLICANT is not the BggwGPARTY proof of authorization to sign is require 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 ENvtRONI ffiNTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. ll <br /> TYPE OF SERVICE REQUESTED: O'J 1 f i.C.✓"LOb� <br /> COMMENTS: �'�� -51a . <br /> (3) SAX /ha-in '5Pra1'✓1 Cp- 1-> p15 <br /> ACCEPTED BY: ��J- �` EMPLOYEE#: DATE: <br /> pUo <br /> ASSIGNED TO: � .(��VV\G�-v�V\ EMPLOYEEM DATE: 9PHlO RpN Wkgt1S <br /> Date Service Completed (if already completed): SERVICE CODE: PIE: '�b <br /> Fee Amount: 2 (.OAmount Paid d 0'� Payment Date 3 �b rJ <br /> Payment Type Invoice# Check# Z� Received By:. <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />