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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> OWNER/ ERA OR �(l{ <br /> L� ,l n� � Ur�l „ CHECKIf BILLING ADDRESS <br /> FACILITY NAME ` Q•� <br /> SIT I= Dl <br /> S <br /> iwf27f� ryhy ,... Q�?� <br /> Street Number retHQn Street Name W 1 CI �1 tN ZI Cotle <br /> HOME Or MAI LIN ADDRESS (If Di f{e ent fromSiteAddr s) <br /> Il l/ tf\l 1" Street Number Street Name <br /> CITYq I Pn I _ Ck oGI TATE ZaP <br /> PHONE#1 M T� Ems• APILAND USE APPLICATION# <br /> (2A GLIO U 2 <br /> PHONE#2 En. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR r <br /> CHECK If BILLING ADDRESS� <br /> BUSINESS NAME PHONE# ExT• <br /> U S ) <br /> HOME Or MAILING ADDRESS " ,1� (AX# ) <br /> CITY C n ll n STATE EPA zip cjs 7 (�, <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. <br /> APPLICANT'S SIGNATURE: off((� � y1 C 1 DATE: <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> !f 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 anW Ni�te it is <br /> provided to me or my representative. E I�ILI� <br /> TYPE OF SERVICE REQUESTED: r F 04M—AA� d <br /> COMMENTS: MAN 14 20 <br /> SM JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> / HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: I„2,(3 DATE: 91412-2 <br /> ASSIGNED TO: EMPLOYEE#: U DATE: 2Z . <br /> Date Service Compleed (If already eompl ed): SERVICE CODE: Yl /_I P/ <br /> Fee Amount: 5Z Amount Paid Z _ Payment Date 1 HOZ L <br /> Payment Type ( 5 Invoice# -Chock# 1 Yp J Received By: <br /> EHD 4M2-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />