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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TA QD122-J-0 S Q 0<Z 5"3(L2 <br /> OWNER/OPERATOR , (i <br /> �A-S/ � CHECK If BILLING ADDRESS <br /> FACILITY NAME <br /> 1' `n,`` <br /> SITE ADDRESS 5Z (� W {'��� 0 Vm n BIW1� D�( �-�0 To V� <br /> Street Number Direction �> Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) �S a . <br /> 3 Y O I T3rV pry e- <br /> Street Number Street Name <br /> CrrY O STAJE f t ZIP `- -5 <br /> PHQNE#; ���I � ExT• APN# LAND USE APPLICATION# <br /> PHOOONNNEE-r#2 EXT. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING AD <br /> BUSINESS NAME I PHONE# EXT, <br /> S U� �� S (5-5°r) 3-77-2219 <br /> HOME or MAILING ADDRESS 1 FAX# <br /> U I 13r vn S) � e d - ( ) <br /> CITY O f)RSTATE 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, e work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards ATE and FED L I ws. II aI, <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <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 and atSaine time it is <br /> provided to me or my representative. 7j <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: <br /> � IA419 MY- <br /> H7. RDp Cou <br /> FPgRTMENl <br /> ACCEPTED BY: EMPLOYEE#: DATE:U —I I .22 <br /> ASSIGNED TO: � LII,� EMPLOYEE#: DATE: l <br /> Date Service Completed (if already completed): SERVICE CODE: 5 P/E: O <br /> Fee Amount: H JU I <br /> Amount Paid L fSL Do Payment Date <br /> Payment Type Invoice# Check# 75Rece ed By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />