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NAN JOAQUIN UOUNTY ENVIRONMENTAL,HEALTH DEPARTMENT <br /> SERVI ,E REQUEST <br /> Type of Busirless or Property FACILITY ID# 7;004;� <br /> VICE REQUEST# <br /> a�r0 M,q f <br /> V1(N R I OPERA ORS CHECK if BILLING ADDRESS D <br /> FACILITY NAME <br /> SITE ADDRESS9 J-30 <br /> 1 Street Number Direction ✓ Street Name C" Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> STATE ZIP s-30 <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> 5 ��Ss. - ll o-2 3 PA-0 d o 6 4u.vO <br /> PHONE# EXT. BOSS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK If BILLING ADDRESS El <br /> BUSINESS NAME PHONE# Exr. <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 or <br /> 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. �t [/ <br /> DATE: <br />} APPLICANT'S SIGNATURE: I / <br /> PROPERTY/BUSINESS OWNER❑ PE OR/MANA R ❑ OTHER AUTHORIZED AGENT❑ <br /> I <br /> y If APPLICANT is not the BILCINGPARTY,proof of authorization to sign is required Tine <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: !77aA- 7--F L pati-4 SO C[— s U-47? ;',645e <br /> COMMENTS: V.Pqlo ( I� I/7��, .�� [�y_,�,'1 RECEIV ��J <br /> i��`�' �Y�// <br /> SAN JOAQUIN COUNT`r <br /> ENVIROOE�RWFAL TMENT <br /> ACCEPTED BY: O�l �> C�/� EMPLOYEE#: DATE: i -Lf 6 <br /> ASSIGNED TO: S �[�a✓17� EMPLOYEE#: �� DATE: 1 Z� O e, <br /> Date Service Completed (if already completed): SERVICE CODE: 5725— PIE: 02_ <br /> Fee Amount: ® Amount Paid .(D-b Payment Date ( C) <br /> Payment Type ✓ Invoice# Check# —Taff Received By: <br /> EHD 48-02-025 ° ,5�2 i ORM,(G�olden'I?ed) <br /> REVISED 1111712003 <br /> I <br />