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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> o()U l33 <br /> OWNER I OPERATOR <br /> 7)n- - C=�J CHECK if BILLING ADDRESS <br /> FACILITY NAME / S _,q Up /T' )� G <br /> SI TE�DDRESS ��V (�'I l(IV > �TI' wTC <br /> Street Number Direction Street Nama CI I Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) 3�-`a. -DOW <br /> t(y <br /> Street Number J �/ 1 I Street Name <br /> CITY 1 I 10 IT <br /> v STATE �) ZIP 9 <br /> PHONE#1 V E APN# LAND USE APPLICATION# V �j <br /> PHONE#2 Ev. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK It BILLING ADDRESS <br /> BUSINESS NAME S'/ n© (y 01 sC0U(/y / „ 0?/l,r PNE#) <br /> ^C L <br /> Exr, <br /> / HOu <br /> HOME or MAILING ADDRESSFAX#�DI 1 690 / (d IF S <br /> CITY S O _ erY STATE (6 zip <br /> BILLING ACKNOWLEDGEMENT: 1, <br /> 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 an FEDERAL laws. <br /> APPLICANT'S SIGNATUR�LAACLdDATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT 11 <br /> if APPLICANT is not the BILL/NG 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 environmentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and {y.@ same time it is <br /> provided to me or my representative. I �A <br /> TYPE OF SERVICE REQUESTED; iv <br /> COMMENTS: <br /> NVjRDNiN CO1JN <br /> TIi 0E N� <br /> unerLho <br /> ACCEPTED BY: LAM EMPLOYEE#: DATE: <br /> ASSIGNED TO: VOW T. <br /> EMPLOYEE 9: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P 1 E: <br /> Fee Amount: Amount Pal ba I Payment Date 2v/ <br /> Payment Type0-0-15 Invoice# Check# Re eived y: <br /> EHD 48.02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> V"NO Vto <br />