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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> �jo NR� <br /> OWNER/OPERATOR CHECK If BILLING ADDRESS 12 <br /> A K D/ mit . Ly N <br /> FACILITY NAME <br /> C <br /> SITE ADDRESS IfTGH�Al50/S( lg4&17EeA X377 <br /> 8 3 Street Number Direction Street Name CIt Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> -5 4 me— Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> P10 > S - / 8 �,g�5-Z- -62 PA g000 <br /> PHONE#T EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> Dv <br /> . /}}}/// <br /> � ��� CHECK if BILLING ADDRESS <br /> BUSINESS NAME �/ PHONE# EXT. <br /> HOME or MAILING DRESS FAX# <br /> 0 3 ( ) <br /> CITY Lo�L STATE O ZIP 061 <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 applic ' and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, ST d FEDERA w . <br /> APPLICANT'S SIGNATURE: DATE; fJ �'o o� <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MAN GER ❑ OTHE AUTFIORIZED 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 anMygW%Te it is <br /> provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: 5 V G <br /> COMMENTS: AUG i 8 20 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> ACCEPTED BY: ��j171 1_ EMPLOYEE#: DATE: <br /> ASSIGNED TO: �� EMPLOYEE#: DATE: e?lt12W <br /> Date Service Completed (if already completed): SERVICE CODE: _ r P/E: �,��,�( <br /> Fee Amount: �6 D Amount Paid t — Payment Date <br /> Payment Type Invoice# Check# j Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />