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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> P-� _ 0 cSe L)C)��t-1 -9SD <br /> OWNER/OPERATOR <br /> CHECK if BILLING ADDRESS <br /> FACILITY NAME <br /> Shu L- S��N �t3Lt <br /> SITE ADDRESS 2 c, ' ( F I C� AUS STJ CL��tJ Gq.5Z.O y- <br /> Street Number Direction Street Name Cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 ExT. APN# LAND USE APPLICATION# <br /> PHONE#2 Ex-r. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR <br /> O O r h evN CHECK If BILLING ADDRESS <br /> BUSINESS NAME IMopo P�S�EtJ PHONE# EXT. <br /> �a 1 -1 1 &4- <br /> HOME or MAILING ADDRESS FAX# <br /> o f t�tL� �i IZ ( ) <br /> CITY � h o p ,t STATE ZIP QI �fl L, 1 <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: l� DATE: -Z-Zl -2,2- <br /> PROPERTY/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT A P-,�f-h I <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 at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED; e,.i In r <br /> COMMENTS: <br /> 09 20 <br /> SAN IV ?? <br /> FIV QUI <br /> N 00E T T� T Y <br /> � <br /> ACCEPTED BY: C—Lw V'T�� S C ' EMPLOYEE#: DATE: 2- <br /> 4 <br /> - <br /> ASSIGNED TO: EMPLOYEE#: DATE: <br /> Date Service Completed (if already completed): SERVICE CODE: P/E: / <br /> Fee Amount: 3 e� 0 �� Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM (Golden Rod) <br /> REVISED 11/17/2003 <br />