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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH "EPARTMENT <br /> �- SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RIPS;DO11" —75p-Inc).3 5�- y <br /> OWNER/OPERATOR ///''' , <br /> �� ` f r• / / I CHECK if BILLING ADDRESS <br /> FACILITY NAME / <br /> SITE <br /> 21sa�,ECJ /n� ✓L 76Street Number Direction Street Name /Code <br /> HOME or MAILING ADDRESS (if Different from Site Address) <br /> r P Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> ( ) Z13— ('Jo-Jo <br /> PHONE#2 ExT. SOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> CHECK if BILLING ADORESSE] <br /> BUSINESS NAME ���—O• N JAN P$E0 �, � ExT <br /> HOME or MAILING ADDRESS FAz# <br /> r V (<So) <br /> CITY l '/iCa y-y-r yl 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 plic uo and that the w to e p ed will be done in accordance with all SAN JoAQuIN <br /> CouNTY Ordinance Codes,Standar ,ST d FEDERAL la s. j <br /> /0 ! <br /> APPLICANT'S SIGNATURE: ATR: <br /> PROPERTY/BUSINESS OWNER OPERATOR/MANA 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: EpE(VED <br /> COMMENTS: <br /> OCT 14 2003 <br /> . • R P06LICH4AE Z"'COUNTY <br /> TH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APPROVED BY: S}}-'tJ- EMPLOYEE#: --1. J-0 DATE: {O —? <br /> ASSIGNED TO: ` , ll•I EMPLOYEE#: 3 DATE:`Q O(/ <br /> Date Service Completed (if already Completed): SERVICE CODE. PIE: <br /> Fee Amount: Amount Paid fid/S� Payment ate `p (0 3 ll <br /> Payment Type V%. Invoice# Check# g'g Received By, <br /> EHD 48-01-025 SERVICE REQUEST FORM <br /> REVISED 6-5-02 <br />