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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> 4 <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> TV-1kDU00 <br /> OWNER/OPERATOR /` D /� ' <br /> ��Q 7 `� /%U /7 G CHECK if BILLING ADDRESS 0 <br /> FACILITY NAME <br /> SITE ADDRESS <br /> /()?- N 01 ,M 0/I <br /> Street Number Direction Street Name cit Zi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) / ,e-01 <br /> Street Number Street Name O <br /> CITY 'S STATE C14 -.C/ <br /> Gj�G v4� <br /> PH9NE#1 EXT APN# LAND USE APPLICATION# <br /> 6S) 3 oG Zi�f 3 <br /> PHONE#2 EXT• BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR / SERVICE REQUESTOR <br /> REQUESTOR C' / el /�G <br /> h G CHECK if BILLING ADDRESS❑ <br /> BUSINESS NAME PHONE# Exr. <br /> HOME Or MAILING ADDRESS FAX# <br /> )4C Dov G/d b V-d ( ) <br /> CITY C Ar/I STATE 04 ZIP 6' <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 WS. <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 at the Same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: grj !j]A <br /> w � �'7ii <br /> 8 MJOA <br /> E&MRCQUtIV C puN <br /> Ty <br /> HrH dE MT NT <br /> ACCEPTED BY: EMPLOYEE#: DATE: 3 ' �? <br /> ASSIGNED TO: EMPLOYEE#: C[� DATE: j �(q'12-3 J <br /> Date Service Com et (if alrea y completed) SERVICE CODE: P 1I„ <br /> Fee Amount: n Amount Paid ((� Payment Date <br /> I <br /> Payment Type Invoice# Check# Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br /> S' <br />