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--1 ��iS heek 1,S GDicl - <br />SAN OAQWCOUNTY ENVIRONMENTAL HEAODEPARTMENT <br />SERVICE REQUEST <br />Type Business o Property <br />%- f t <br />FACILITY ID # <br />C'MMENTS. <br />SERVICE REQUEST # <br />_% <br />DEC 16 2004 ' <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />372 <br />VLf UE /" <br />sR004-0coct 1 <br />OWNE OPERATOR <br />S�-rr <br />CHECK If BILLING ADDRESS <br />FACILITY NAME <br />EMPLOYEE#: <br />SITE ADDRESS 5 O CL <br />( \S <br />Date Service Completed (if already completed): <br />- <br />SERVICE CODE (g �/ <br />P 1 E:?(((t(L 0 fl <br />-,aunt <br />Street Number <br />Direction <br />Street Name <br />Ci <br />Zip Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />ecei d By: <br />Street Number <br />Street Name <br />CITY <br />STATE ZIP <br />PHONE #1 EXT' <br />0"', � 65- - 3Y <br />APN # <br />LAND USE '� PLICATION # <br />PHONE#2 EXT. <br />( I <br />BOS DISTRICT <br />LOCATION CODE <br />REQUESTOR <br />BUSINESS <br />CONTRACTORt__I SERVICE REQUESTOR <br />e/� <br />y1 \ e-- \ - I ,nb CHECK " 1ILLING AI <br />u= or "AA, <br />-INGACrDRESS <br />"_IT'f __"-- <br />PHONE EXT- <br />FAX k <br />STATE`''P .���GL,S�_—___ <br />;,lL_..:i: JV! R;DGEMci1T: I, t uua 11,icd prorrrty u -s business owner, o, erator or a-T'hnri= R - <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 .is 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 accorda.r:e with ali ;; -,;' et:i.•+ <br />'.UUNTY Ordinance Codes, Stand rds, STATE :rod FEDERAL laws. <br />APPLICANT'S SIGNATURE:(� 0 O Q.-- DATE: 12-16-09 <br />PROPERTY/ BUSINESS OWNER OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT', <br />OJAPPLICA is no the BILLINGPARTY, proof of authorization to sign is required Title <br />AUTHORIZATION TO ASS 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 />infonm2tioh to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to Ine or my representative. PAYMENT <br />TYPE OF SERVICE REQUESTED: (,(ST <br />%- f t <br />C'MMENTS. <br />- <br />_% <br />DEC 16 2004 ' <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />.'FHOVEO BY: <br />VLf UE /" <br />I EMPLOYEE #: <br />032 P <br />ASSIGNED TO: <br />A-16, <br />EMPLOYEE#: <br />8 0 tf <br />y)ATE:1& fi . <br />Date Service Completed (if already completed): <br />- <br />SERVICE CODE (g �/ <br />P 1 E:?(((t(L 0 fl <br />-,aunt <br />n <br />�27 `1- pai" [ —. <br />Payment F> <br />Payment Type <br />Invoice If <br />Check # <br />ecei d By: <br />EHD 48-01-025 SERVICE REQUEST FORM <br />REVISED 6-5-02 <br />