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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# FS-4 <br /> ERVICE REQUEST# <br /> T—� 002 -1og5 OD9` 15 <br /> OWNER/OPERATOR Q <br /> CHECK((BILLING ADDRESS <br /> FACILITY NAME <br /> SITE ADDRESS <br /> Street Number Diredlon l.� Street Name 'l �CIv ZI Code <br /> HOME.0 _AILI_NG A (If D' nt fr Site Addr ss) <br /> Street Number Street Name <br /> CITY LO� STATE A ZIP Q� <br /> PHONE I#`�,I Exr' APN# LAND USE APPLICATION# <br /> ( -1 <br /> 20 <br /> PHONE#2 <br /> CIo -36 3S En BOS DISTRICT LOCATION CODE <br /> 6 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTORCHECK If BILLING ADDRESS <br /> "F�i�nGiSGG Sml✓r�c�ts►2 1A /VI.kS <br /> BUSINESS NAMEP Ear' <br /> �I GSI iW i (o�Y -��� � <br /> HOME Or MAILING ADDRESS FAX# <br /> u SS ( ) <br /> CITY L ._ \ STATE C4_ ZIP C)7j-')S <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,ST TE and FEDERAL laws—) �Xj J� �j <br /> APPLICANT'S SIGNATURE: / DATE: " 1✓OIL I <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT[I <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 anGyftthe same time It is <br /> provided to me or my representative. n 1� I`AY <br /> TYPE OF SERVICE REQUESTED: �cc <br /> COMMENTS: 06J') 1 � Ailc go <br /> y DFagR7-T�.q�4o?�Y <br /> MFNT <br /> ACCEPTED BY: EMPLOYEE#: DATE: O <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICECODE: 452-3 PIE: l� <br /> Fee Amount: Amount Pa'd 5 Payment Date 2 113 0 <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />