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SAN JOAQUIN COUN'T'Y ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 2 0C950V!::> <br /> OWNER/OPERATOR <br /> q O �} r q CHECK If BILLING ADDRESS ri <br /> FACILITY NAME C L ` l`M n <br /> SITE ADDRESS �,g3�1°PI Zyyd WA <br /> L f�Sfreet Number oiractlon I ✓ Streel Name 1 w C Zip Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) ' iI <br /> 3 Street Number Street Name w `C <br /> CITY STATE ZIP <br /> 08 :5 Irat Allen q5 ZO <br /> PHONE#1 Em APN# LAND USE APPLICATION# <br /> PHONE#2 Em BOIS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EzT• <br /> ) <br /> HOME or MAILING ADDRESS 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, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: 3MIV "tl co-m 'Z DATE: 3=1 3-2_0-n <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT❑ <br /> IfAPPLICAArT is not the BILLlNGPAKTY 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 at the same time it is <br /> provided to me or my representative. p <br /> TYPE OF SERVICE REQUESTED: �� �i0 eC <br /> COMMENTS: <br /> AR 15 20 <br /> 22 <br /> QUI arty , <br /> �nbElyl• <br /> ACCEPTED BY: <br /> EMPLOYEE 62�� DATE: / ZZ <br /> ASSIGNED 70: EMPLOYEE#: g Z �yj DATE: / Z <br /> Date Service Compl6ted4if already completed): SERVICE CODE: p& (ro� I E: <br /> Fee Amount: l�� Amount Paid �a Payment Date 2 ei22 <br /> Payment Type Invoice# 0597-7Q 3 1 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />