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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME T f <br /> SERVICE REQUEST " f r-" I' <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# y�) <br /> OWNER/OP RATOR <br /> v 1 A CHECKIf BILLING ADDRESS <br /> FACILITY NAMEUJ Ste , � R— ` J <br /> `M1 <br /> SITE ADDRESS (/ 1 <br /> Street Number Direction Street Name CityZi Code <br /> _ <br /> HOME or MAILING DRRF,ISS/'(if Different from SiteCAddddre)s,51}�tL <br /> "✓� t Y �'� '� 1 Street Number (2A, Street Name <br /> ClSTATE Zr-741I' � Gc-b-)Yq %S2TO <br /> PHOE#1 APN# LAND USE APPLICATION# <br /> Q'C� ) 1;-b-) - s a3 <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME q e C iJ^Q� � PHONE# E <br /> ,r HOMEor MAIL NGADDDRE <br /> J5 FAX# <br /> CITY STATE ZIP <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,S ATE FEDERAL laws. <br /> APPLICANT'S SIGNATURE:SIGNATURE: DATE: "P-C) <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR M CER ❑ OTHER AUTHORIZED AGENT❑ <br /> /f APPLICANT is not the B26GVGPARrr proof of authorization to sign is required rule <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 and at the same time it is <br /> provided to me or my representative. P <br /> TYPE OF SERVICE REQUESTED: CC T <br /> COMMENTS: J�/Y <br /> %del Qu/ ?0?? <br /> p���RCAI CD � <br /> t/� H�EpgR�NT <br /> ACCEPTED BY: j LA r12 EMPLOYEE#: DATE: Z l 2 <br /> ASSIGNED TO: "I EMPLOYEE#: 4y DATE: I 2 2/2 <br /> Date Service Completed (if already completed): SERVICE CODE: l P i E: � O3 <br /> Fee Amount: Amount Pal jv Payment Date z7 V <br /> Payment Type Invoice# Check# 13 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 qjY t5�j-I Lf q5- <br />