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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE RE41ST# <br /> S�K60� (��l I <br /> OWNER/OPERATOR <br /> LI 012 h c `lb) CHECK If BILLING ADDRESS <br /> FACILITY NAME L•tt—til t r`Kl T�rl FYI �I <br /> SITE ADDRESS <br /> et Number Direction Street Name ( V CI V/Z71 Codev <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> t7 Street Number Street Name <br /> CITY Lo <br /> t Q, STATE ZIP 3.50 <br /> PHONE#t E�'• APN# LAND USE APPLICATION# <br /> (,aO 309 — 9 aL/ <br /> PH E#Z EK• BOS DISTRICT LOCATION CODE <br /> c og> asv - 888 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQ U�STQ.R}/�oit (y <br /> t r<"�J 1"'!� CHECK If BILLING ADDRESS <br /> BUSINE ASE k, ,`0• PHON # O ^ EM <br /> HOME Or AIL GAADRTESSr' FAx# S 5 <br /> c D <br /> CITY n /l,p- STATE zip qS3 3 0 <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: c DATE; 'A <br /> PROPERTY/BUSINESS OWNER❑ OPERA OR/MANAGER ❑ OTHER AUTHORaED AGENT 11 <br /> IfAPPAtcANT is not the BILLING PAR TP proof ofauthorization 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 assssess'sTm ent <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and F11t is <br /> provided to me or my representative. RECEIVED <br /> TYPE OF SERVICE REQUESTED: <br /> APR 16 2W- <br /> COMMENTS: <br /> SAN JOAQUIN COUNT) <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMEN <br /> ACCEPTED BY: S. <br /> EMPLOYEE#: WU DATE: <br /> ASSIGNED TO: ^ ( ', EMPLOYEE#: ' y�L f DATE: 2 fd <br /> Date Service Completed (if already completed): SERVICE CODE: UP I <br /> iE: 1 3 <br /> Fee Amount: Amount Paid #ZS 2 Payment Date � L <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11117/2003 <br />