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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> G / 500 4v531 <br /> OWNER/OPERATOR <br /> CHECK If BILLING ADDRES <br /> FACILITY NAME G j <br /> WE ADDRESS <br /> /L Street Number I Drection <br /> HOME Or MAILING ADDRESS (If Different from Site Address) �D/ � <br /> street Nu her t el am <br /> CIN STATE ZIP <br /> NDS�� <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (20 2Jf T LD / <br /> PHONE#2 EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR ,�� <br /> / J CHECK if BILLING ADDRE55O <br /> BUSINESS NAME —� /71;701r& olz� PHONE# EXT. <br /> HOME or MAILING ADDR l MA� <br /> CITY / / C-/ STATE ,p• Zip <br /> BILLING GACKNOWLEDGEMENT: 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 applicatio and that t�a work to be erformed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards,STATE DE (L laws. / ^� <br /> APPLICANT'S SIGNATURE: DATE: <br /> �y ///��e� ��� O� <br /> PROPERTY/BUSINESS OWNER❑ OF <br /> BATOR/11I CER ❑ QT R AUTHORIZED AGEN"ILCTa <br /> IfAPPLICAN Ot the lLLINGPART proof of author ation to sign is required Title <br /> AUTHORIZATION TO RELEAS INFORMA ION: 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: t t/ P1YME <br /> IVED <br /> RECE <br /> o-C _ 2 2004 <br /> SAN JOAQUIN COUNTY <br /> V"nEPARTMENT <br /> APPROVED BY: OLt I A EMPLOYEE#: ©32 ' DATE: , O <br /> ASSIGNED TO: EMPLOYEE#: .j-73 DATE: �Z y.1 A <br /> Date Service Completed (if already ompleted): SERVICE CODE: PIE; <br /> 03 f g3 d3. 0 <br /> Fee Amount:' , - q Amount Paid Payment Da e <br /> Payment Type _ Invoice# - <br /> Check# Received By: <br /> EHD 48-01-025 <br /> REVISED 6-5-02 SERVICE REQUEST FORI�y(f <br />