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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />B1!�k 0,e;Wl <br />I <br />FACILITY ID # <br />jxolX20 <br />SERVICE REQUEST # <br />'542 ylse;f L1 <br />OWNER / OPERATOR /, <br />ale <br />CITY OL. STATE <br />CHECK if BILLING ADDRESS <br />^ <br />FACILITY NAME 7�/� , Y// e K <br />d (If already completed): <br />SERVICE CODE: <br />SITE ADDRESS /S/ <br />Street Number <br />Direction <br />Street Name <br />CKV <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 ExT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE#2 Exr. <br />( ) <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTORW !D O <br />' G(/ ( C/t" CHECK if BILLING ADDRESS <br />BUSINESS NAME�-f—J11 de4S <br />PHONE# p T <br />O <br />HOME or MAILING ADDRESS/5/ (� �7/ /� „[_ <br />FAX# <br />CITY OL. STATE <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 we 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 SIGNATUrR�E/: � OG,�yya� DATE: 7 ! 2OZZ <br />PROPERTY / BUSINESS OwNERL:I 'OPERATOR/ MANAGER ❑ Ormit AuTuomZED AGENT ❑ CJS� <br />If APPL/CANT is not the BHIMG PARTY proof of authorization to sign is required Time <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 environmen to assessment <br />information to the SAN JoAQuiN CouNTY ENvntoNMEIdTAL HEALTH DEPARTMENT as soon as it is available and at ��ei+it is <br />provided to me or my representative. RF(��.,. 'VIP <br />TYPE OF SERVICE REQUESTED: <br />COMMENTS: <br />J0.1 Q9'R/Tty2F0N� <br />T 2 <br />gINhFMPTNCOg4PE'ENT7'� <br />' <br />ACCEPTED BY: <br />I vl <br />EMPLOYEE J <br />V <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE#: O! <br />DATE: (( Z <br />Date Service Comple <br />d (If already completed): <br />SERVICE CODE: <br />P/E:1(/0/ <br />Fee Amout/� <br />Amount Paid D <br />Payment Date ZZ <br />Payment Type <br />Invoice # <br />3! t <br />Received By: ki <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />