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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SER <br /> VI <br /> CE REQUEST# <br /> OWNER I OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME wel,^ <br /> SITE ADDRESS bg <br /> Street Number Dlre&ion Street Name City Zip Code <br /> HOME or MAILING ADDRESS (If afferent fr Si Addr ss) (�/ <br /> ZL C/ ` dstreet Number Street Name <br /> CITY STATE ^ <br /> PHONE#1 E'T• APN# LAND USE APPLICAT/IKON#!/�/_ U <br /> PHONE#2 Em BOS DISTRICT LOCATION CODE <br /> ( Lt 0 ' S100 <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADORES <br /> BUSINESS NAME C`kl� <br /> PHONE# Ev. <br /> � U !�x Q <br /> HOME or MAILING ADDRESS FAx# <br /> CITY / /` A STATE l ZIP S &11 <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 attd ED L laws. <br /> APPLICANT'S SIGNATURE: / DATE: <br /> PROPERTY/BUSINESS OWNER ERATOR/MANAGER ❑ THER AUTHORIZED AGENT❑ <br /> I'APPLICANT is not the BILLING PARTY proof of authorization to sign is required Tarte <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 t Same time it is <br /> provided to me or my representative. �/Y <br /> TYPE OF SERVICE REQUESTED: CErV <br /> COMMENTS: OCr z <br /> zozz <br /> `MNJOAQUIV <br /> NFAL7H pE AS �� <br /> ACCEPTED BY: LAMM EMPLOYEE#: U�(] DATE: I O ZS 22 <br /> ASSIGNED TO: t o EMPLOYEE#: I DATE: f 0 'L5 <br /> Date Service Completed (if already Completed): SERVICE CODE: I P/E: I <br /> Fee Amount: l U-�Amount Paid I S� Dzj Payment Date ZS <br /> Payment Type Invoice# Check# h.S/9�332 2— Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 ^ <br /> P�oS(f812o J <br />